- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.65 / $4,332.60 / $4,332.60
| Professional | | $868.65 | $4,332.60 | $4,332.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,317.65 / $1,317.65 / $1,317.65
| Facility | | $1,317.65 | $1,317.65 | $1,317.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.13 / $1,317.65 / $1,351.40
| Professional | | $925.13 | $1,317.65 | $1,351.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $651.00 / $1,466.40 / $1,532.55
| Facility | | $651.00 | $1,466.40 | $1,532.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.63 / $1,202.57 / $1,734.60
| Professional | | $801.63 | $1,202.57 | $1,734.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.56 / $1,432.80 / $2,301.39
| Professional | | $1,150.56 | $1,432.80 | $2,301.39 |