- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $4,297.29 / $4,297.29
| Professional | | $935.26 | $4,297.29 | $4,297.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,308.72 / $1,308.72
| Facility | | $1,308.72 | $1,308.72 | $1,308.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.38 / $1,308.72 / $1,308.72
| Professional | | $972.38 | $1,308.72 | $1,308.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,557.40 / $1,606.55
| Facility | | $1,308.72 | $1,557.40 | $1,606.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.63 / $1,135.67 / $1,734.60
| Professional | | $801.63 | $1,135.67 | $1,734.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.95 / $1,451.41 / $2,293.06
| Professional | | $1,221.95 | $1,451.41 | $2,293.06 |