- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.89 / $4,905.12 / $4,905.12
| Professional | | $669.89 | $4,905.12 | $4,905.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.34 / $1,341.05 / $1,341.05
| Facility | | $1,057.34 | $1,341.05 | $1,341.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.34 / $1,090.56 / $1,341.05
| Professional | | $1,057.34 | $1,090.56 | $1,341.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.88 / $1,277.19 / $1,341.05
| Facility | | $710.88 | $1,277.19 | $1,341.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.52 / $1,057.34 / $1,342.02
| Professional | | $1,006.52 | $1,057.34 | $1,342.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.92 / $636.11 / $728.17
| Professional | | $574.92 | $636.11 | $728.17 |