- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.55 / $4,760.43 / $4,760.43
| Professional | | $953.55 | $4,760.43 | $4,760.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,441.74 / $1,441.74 / $1,441.74
| Facility | | $1,441.74 | $1,441.74 | $1,441.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.43 / $1,441.74 / $1,508.54
| Professional | | $1,025.43 | $1,441.74 | $1,508.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.76 / $1,593.15 / $1,678.66
| Facility | | $706.76 | $1,593.15 | $1,678.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.98 / $1,317.10 / $1,899.80
| Professional | | $877.98 | $1,317.10 | $1,899.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.00 / $1,568.63 / $2,525.23
| Professional | | $1,250.00 | $1,568.63 | $2,525.23 |