- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.41 / $4,485.72 / $4,485.72
| Professional | | $975.41 | $4,485.72 | $4,485.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.96 / $1,384.96 / $1,384.96
| Facility | | $1,384.96 | $1,384.96 | $1,384.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.72 / $1,384.96 / $1,386.91
| Professional | | $877.72 | $1,384.96 | $1,386.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.51 / $1,417.65 / $1,540.77
| Facility | | $675.51 | $1,417.65 | $1,540.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.54 / $1,272.94 / $1,836.10
| Professional | | $848.54 | $1,272.94 | $1,836.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.04 / $1,417.65 / $2,443.85
| Professional | | $1,143.04 | $1,417.65 | $2,443.85 |