- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.62 / $3,622.50 / $3,622.50
| Professional | | $715.62 | $3,622.50 | $3,622.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,081.57 / $1,081.57 / $1,081.57
| Facility | | $1,081.57 | $1,081.57 | $1,081.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.09 / $1,081.57 / $1,133.74
| Professional | | $775.09 | $1,081.57 | $1,133.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.82 / $1,246.05 / $1,287.77
| Facility | | $534.82 | $1,246.05 | $1,287.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.88 / $976.42 / $1,408.40
| Professional | | $650.88 | $976.42 | $1,408.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.67 / $1,226.86 / $1,879.60
| Professional | | $977.67 | $1,226.86 | $1,879.60 |