- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.72 / $1,037.96 / $3,862.94
| Professional | | $670.72 | $1,037.96 | $3,862.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,180.42 / $1,180.42 / $1,180.42
| Facility | | $1,180.42 | $1,180.42 | $1,180.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.71 / $1,180.42 / $1,237.33
| Professional | | $613.71 | $1,180.42 | $1,237.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.67 / $803.94 / $1,180.42
| Facility | | $584.67 | $803.94 | $1,180.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.73 / $1,180.42 / $1,537.90
| Professional | | $710.73 | $1,180.42 | $1,537.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.21 / $1,197.44 / $1,361.92
| Professional | | $954.21 | $1,197.44 | $1,361.92 |