- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.52 / $3,778.23 / $3,778.23
| Professional | | $789.52 | $3,778.23 | $3,778.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,119.43 / $1,119.43 / $1,119.43
| Facility | | $1,119.43 | $1,119.43 | $1,119.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.45 / $1,119.43 / $1,187.85
| Professional | | $762.45 | $1,119.43 | $1,187.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.92 / $1,192.75 / $1,299.79
| Facility | | $547.92 | $1,192.75 | $1,299.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.41 / $1,032.72 / $1,489.60
| Professional | | $688.41 | $1,032.72 | $1,489.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.91 / $1,192.75 / $1,978.58
| Professional | | $956.91 | $1,192.75 | $1,978.58 |