- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.94 / $4,290.82 / $4,290.82
| Professional | | $859.94 | $4,290.82 | $4,290.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.35 / $1,301.35 / $1,301.35
| Facility | | $1,301.35 | $1,301.35 | $1,301.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.25 / $1,301.35 / $1,337.44
| Professional | | $925.25 | $1,301.35 | $1,337.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $637.58 / $1,433.90 / $1,510.41
| Facility | | $637.58 | $1,433.90 | $1,510.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.25 / $1,188.50 / $1,714.30
| Professional | | $792.25 | $1,188.50 | $1,714.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.07 / $1,400.66 / $2,281.98
| Professional | | $1,125.07 | $1,400.66 | $2,281.98 |