- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.20 / $1,076.81 / $4,007.46
| Professional | | $817.20 | $1,076.81 | $4,007.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,224.06 / $1,224.06 / $1,224.06
| Facility | | $1,224.06 | $1,224.06 | $1,224.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.91 / $1,224.06 / $1,285.06
| Professional | | $652.91 | $1,224.06 | $1,285.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.38 / $833.77 / $1,224.06
| Facility | | $606.38 | $833.77 | $1,224.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.58 / $1,224.06 / $1,596.00
| Professional | | $737.58 | $1,224.06 | $1,596.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.14 / $1,280.64 / $1,424.93
| Professional | | $1,078.14 | $1,280.64 | $1,424.93 |