- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.22 / $4,803.66 / $4,803.66
| Professional | | $890.22 | $4,803.66 | $4,803.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.16 / $1,450.16 / $1,450.16
| Facility | | $1,450.16 | $1,450.16 | $1,450.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.29 / $1,450.16 / $1,520.60
| Professional | | $905.29 | $1,450.16 | $1,520.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $813.12 / $988.47 / $2,032.22
| Facility | | $813.12 | $988.47 | $2,032.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.01 / $1,450.16 / $1,778.04
| Professional | | $877.01 | $1,450.16 | $1,778.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.50 / $1,525.98 / $1,683.84
| Professional | | $1,290.50 | $1,525.98 | $1,683.84 |