- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.65 / $1,303.94 / $4,869.89
| Professional | | $993.65 | $1,303.94 | $4,869.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,480.65 / $1,480.65 / $1,480.65
| Facility | | $1,480.65 | $1,480.65 | $1,480.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.91 / $1,287.38 / $1,480.65
| Professional | | $630.91 | $1,287.38 | $1,480.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.60 / $917.00 / $1,418.07
| Facility | | $733.60 | $917.00 | $1,418.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.12 / $1,395.65 / $1,936.90
| Professional | | $895.12 | $1,395.65 | $1,936.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.14 / $1,508.07 / $1,706.81
| Professional | | $1,208.14 | $1,508.07 | $1,706.81 |