- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.24 / $1,044.35 / $3,899.14
| Professional | | $792.24 | $1,044.35 | $3,899.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,195.67 / $1,195.67 / $1,195.67
| Facility | | $1,195.67 | $1,195.67 | $1,195.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.07 / $1,195.67 / $1,335.69
| Professional | | $688.07 | $1,195.67 | $1,335.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.09 / $811.37 / $1,195.67
| Facility | | $590.09 | $811.37 | $1,195.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.11 / $1,195.67 / $1,558.20
| Professional | | $720.11 | $1,195.67 | $1,558.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.34 / $1,237.14 / $1,365.11
| Professional | | $961.34 | $1,237.14 | $1,365.11 |