- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.65 / $4,512.38 / $4,512.38
| Professional | | $999.65 | $4,512.38 | $4,512.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.43 / $1,384.43 / $1,384.43
| Facility | | $1,384.43 | $1,384.43 | $1,384.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.33 / $1,384.43 / $1,384.43
| Professional | | $1,137.33 | $1,384.43 | $1,384.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.43 / $1,762.15 / $1,811.48
| Facility | | $1,384.43 | $1,762.15 | $1,811.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.89 / $1,201.20 / $1,834.70
| Professional | | $847.89 | $1,201.20 | $1,834.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.73 / $1,551.61 / $2,417.01
| Professional | | $1,344.73 | $1,551.61 | $2,417.01 |