- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.25 / $4,262.68 / $4,262.68
| Professional | | $854.25 | $4,262.68 | $4,262.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,293.47 / $1,293.47 / $1,293.47
| Facility | | $1,293.47 | $1,293.47 | $1,293.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.62 / $1,293.47 / $1,327.54
| Professional | | $901.62 | $1,293.47 | $1,327.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $633.71 / $1,415.70 / $1,493.97
| Facility | | $633.71 | $1,415.70 | $1,493.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.08 / $1,180.73 / $1,703.10
| Professional | | $787.08 | $1,180.73 | $1,703.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.25 / $1,393.92 / $2,268.09
| Professional | | $1,108.25 | $1,393.92 | $2,268.09 |