- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.47 / $3,456.77 / $3,456.77
| Professional | | $683.47 | $3,456.77 | $3,456.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.57 / $1,030.57 / $1,030.57
| Facility | | $1,030.57 | $1,030.57 | $1,030.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.27 / $1,030.57 / $1,097.65
| Professional | | $754.27 | $1,030.57 | $1,097.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $509.75 / $1,264.25 / $1,298.52
| Facility | | $509.75 | $1,264.25 | $1,298.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.12 / $931.78 / $1,344.00
| Professional | | $621.12 | $931.78 | $1,344.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.89 / $1,136.41 / $1,788.95
| Professional | | $984.89 | $1,136.41 | $1,788.95 |