- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.41 / $4,232.75 / $4,232.75
| Professional | | $925.41 | $4,232.75 | $4,232.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,315.03 / $1,315.03 / $1,315.03
| Facility | | $1,315.03 | $1,315.03 | $1,315.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.42 / $1,315.03 / $1,315.03
| Professional | | $835.42 | $1,315.03 | $1,315.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $1,326.65 / $1,448.43
| Facility | | $642.26 | $1,326.65 | $1,448.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.13 / $1,210.82 / $1,746.50
| Professional | | $807.13 | $1,210.82 | $1,746.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.48 / $1,326.66 / $2,320.82
| Professional | | $1,073.48 | $1,326.66 | $2,320.82 |