- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.86 / $4,804.60 / $4,804.60
| Professional | | $910.86 | $4,804.60 | $4,804.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,469.09 / $1,469.09 / $1,469.09
| Facility | | $1,469.09 | $1,469.09 | $1,469.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.12 / $1,469.09 / $1,515.91
| Professional | | $975.12 | $1,469.09 | $1,515.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $829.13 / $1,021.54 / $2,019.60
| Facility | | $829.13 | $1,021.54 | $2,019.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.12 / $1,469.09 / $1,818.83
| Professional | | $895.12 | $1,469.09 | $1,818.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.68 / $1,532.94 / $1,675.13
| Professional | | $1,360.68 | $1,532.94 | $1,675.13 |