- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.33 / $4,353.52 / $4,353.52
| Professional | | $873.33 | $4,353.52 | $4,353.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.86 / $1,321.86 / $1,321.86
| Facility | | $1,321.86 | $1,321.86 | $1,321.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.30 / $1,321.86 / $1,357.81
| Professional | | $928.30 | $1,321.86 | $1,357.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $647.66 / $1,448.20 / $1,527.49
| Facility | | $647.66 | $1,448.20 | $1,527.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.54 / $1,206.94 / $1,740.90
| Professional | | $804.54 | $1,206.94 | $1,740.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.28 / $1,425.92 / $2,317.11
| Professional | | $1,136.28 | $1,425.92 | $2,317.11 |