- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.71 / $1,249.55 / $4,692.55
| Professional | | $899.71 | $1,249.55 | $4,692.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,359.72 / $1,359.72 / $1,359.72
| Facility | | $1,359.72 | $1,359.72 | $1,359.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.93 / $1,359.72 / $1,413.68
| Professional | | $739.93 | $1,359.72 | $1,413.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.15 / $925.58 / $1,359.72
| Facility | | $673.15 | $925.58 | $1,359.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.54 / $1,359.72 / $1,788.50
| Professional | | $826.54 | $1,359.72 | $1,788.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.71 / $1,462.18 / $2,229.06
| Professional | | $1,285.71 | $1,462.18 | $2,229.06 |