- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.39 / $1,207.82 / $4,506.30
| Professional | | $918.39 | $1,207.82 | $4,506.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.34 / $1,372.34 / $1,372.34
| Facility | | $1,372.34 | $1,372.34 | $1,372.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.65 / $1,372.34 / $1,447.43
| Professional | | $742.65 | $1,372.34 | $1,447.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.42 / $934.21 / $1,372.34
| Facility | | $679.42 | $934.21 | $1,372.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.16 / $1,372.34 / $1,792.00
| Professional | | $828.16 | $1,372.34 | $1,792.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.83 / $1,393.28 / $1,995.00
| Professional | | $1,138.83 | $1,393.28 | $1,995.00 |