- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.92 / $3,409.96 / $3,409.96
| Professional | | $755.92 | $3,409.96 | $3,409.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.68 / $1,073.68 / $1,073.68
| Facility | | $1,073.68 | $1,073.68 | $1,073.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.48 / $1,073.68 / $1,073.68
| Professional | | $652.48 | $1,073.68 | $1,073.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.37 / $1,073.68 / $1,145.46
| Facility | | $519.37 | $1,073.68 | $1,145.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.88 / $992.92 / $1,432.20
| Professional | | $661.88 | $992.92 | $1,432.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.75 / $1,076.76 / $1,899.94
| Professional | | $857.75 | $1,076.76 | $1,899.94 |