- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.85 / $3,751.88 / $3,751.88
| Professional | | $740.85 | $3,751.88 | $3,751.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.48 / $1,120.48 / $1,120.48
| Facility | | $1,120.48 | $1,120.48 | $1,120.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.16 / $1,120.48 / $1,200.67
| Professional | | $822.16 | $1,120.48 | $1,200.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.46 / $1,326.65 / $1,372.53
| Facility | | $554.46 | $1,326.65 | $1,372.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.85 / $1,010.88 / $1,458.10
| Professional | | $673.85 | $1,010.88 | $1,458.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.92 / $1,224.92 / $1,946.21
| Professional | | $1,040.92 | $1,224.92 | $1,946.21 |