- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.37 / $4,733.84 / $4,733.84
| Professional | | $936.37 | $4,733.84 | $4,733.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.25 / $1,411.25 / $1,411.25
| Facility | | $1,411.25 | $1,411.25 | $1,411.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.71 / $1,411.25 / $1,500.98
| Professional | | $1,012.71 | $1,411.25 | $1,500.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $698.35 / $1,676.35 / $1,719.14
| Facility | | $698.35 | $1,676.35 | $1,719.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.81 / $1,276.33 / $1,841.00
| Professional | | $850.81 | $1,276.33 | $1,841.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.11 / $1,557.61 / $2,453.10
| Professional | | $1,220.11 | $1,557.61 | $2,453.10 |