- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.57 / $3,791.52 / $3,791.52
| Professional | | $778.57 | $3,791.52 | $3,791.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.68 / $1,073.68 / $1,073.68
| Facility | | $1,073.68 | $1,073.68 | $1,073.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.29 / $1,073.68 / $1,073.68
| Professional | | $875.29 | $1,073.68 | $1,073.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.68 / $1,387.75 / $1,445.90
| Facility | | $1,073.68 | $1,387.75 | $1,445.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.62 / $934.47 / $1,427.30
| Professional | | $659.62 | $934.47 | $1,427.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.85 / $1,293.59 / $1,877.75
| Professional | | $1,088.85 | $1,293.59 | $1,877.75 |