- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.37 / $3,529.92 / $3,529.92
| Professional | | $691.37 | $3,529.92 | $3,529.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.91 / $1,057.91 / $1,057.91
| Facility | | $1,057.91 | $1,057.91 | $1,057.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.33 / $1,057.91 / $1,147.70
| Professional | | $760.33 | $1,057.91 | $1,147.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.84 / $1,181.05 / $1,289.04
| Facility | | $516.84 | $1,181.05 | $1,289.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.74 / $967.20 / $1,395.10
| Professional | | $644.74 | $967.20 | $1,395.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.67 / $1,146.00 / $1,861.10
| Professional | | $926.67 | $1,146.00 | $1,861.10 |