- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.22 / $4,057.50 / $4,057.50
| Professional | | $971.22 | $4,057.50 | $4,057.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.33 / $1,209.33 / $1,209.33
| Facility | | $1,209.33 | $1,209.33 | $1,209.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.36 / $1,209.33 / $1,307.75
| Professional | | $878.36 | $1,209.33 | $1,307.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $598.12 / $1,440.40 / $1,493.97
| Facility | | $598.12 | $1,440.40 | $1,493.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.49 / $1,094.34 / $1,578.50
| Professional | | $729.49 | $1,094.34 | $1,578.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.16 / $1,334.40 / $2,101.60
| Professional | | $1,130.16 | $1,334.40 | $2,101.60 |