- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.19 / $3,843.51 / $3,843.51
| Professional | | $766.19 | $3,843.51 | $3,843.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,156.76 / $1,156.76 / $1,156.76
| Facility | | $1,156.76 | $1,156.76 | $1,156.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.52 / $1,156.76 / $1,214.05
| Professional | | $850.52 | $1,156.76 | $1,214.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $567.04 / $1,300.65 / $1,369.36
| Facility | | $567.04 | $1,300.65 | $1,369.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.58 / $1,056.98 / $1,524.60
| Professional | | $704.58 | $1,056.98 | $1,524.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.51 / $1,278.59 / $2,027.60
| Professional | | $1,020.51 | $1,278.59 | $2,027.60 |