- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.49 / $4,105.81 / $4,105.81
| Professional | | $831.49 | $4,105.81 | $4,105.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.33 / $1,260.33 / $1,260.33
| Facility | | $1,260.33 | $1,260.33 | $1,260.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.18 / $1,260.33 / $1,260.33
| Professional | | $842.18 | $1,260.33 | $1,260.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.21 / $1,320.80 / $1,365.57
| Facility | | $616.21 | $1,320.80 | $1,365.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.34 / $1,151.13 / $1,660.40
| Professional | | $767.34 | $1,151.13 | $1,660.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.55 / $1,313.70 / $2,207.05
| Professional | | $1,064.55 | $1,313.70 | $2,207.05 |