- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.40 / $3,996.10 / $3,996.10
| Professional | | $788.40 | $3,996.10 | $3,996.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.86 / $1,209.86 / $1,209.86
| Facility | | $1,209.86 | $1,209.86 | $1,209.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.14 / $1,209.86 / $1,234.42
| Professional | | $856.14 | $1,209.86 | $1,234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.60 / $1,355.90 / $1,395.93
| Facility | | $596.60 | $1,355.90 | $1,395.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.08 / $1,098.23 / $1,584.10
| Professional | | $732.08 | $1,098.23 | $1,584.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.85 / $1,312.20 / $2,105.29
| Professional | | $1,063.85 | $1,312.20 | $2,105.29 |