- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.05 / $4,181.31 / $4,181.31
| Professional | | $920.05 | $4,181.31 | $4,181.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,280.32 / $1,280.32 / $1,280.32
| Facility | | $1,280.32 | $1,280.32 | $1,280.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.38 / $1,280.32 / $1,382.25
| Professional | | $928.38 | $1,280.32 | $1,382.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.83 / $1,494.35 / $1,541.40
| Facility | | $630.83 | $1,494.35 | $1,541.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.61 / $1,171.03 / $1,689.10
| Professional | | $780.61 | $1,171.03 | $1,689.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.11 / $1,493.23 / $2,236.64
| Professional | | $1,225.11 | $1,493.23 | $2,236.64 |