- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.04 / $1,272.67 / $4,738.47
| Professional | | $968.04 | $1,272.67 | $4,738.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,446.48 / $1,446.48 / $1,446.48
| Facility | | $1,446.48 | $1,446.48 | $1,446.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.44 / $1,446.48 / $1,516.11
| Professional | | $766.44 | $1,446.48 | $1,516.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.10 / $984.64 / $1,446.48
| Facility | | $716.10 | $984.64 | $1,446.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.13 / $1,446.48 / $1,889.30
| Professional | | $873.13 | $1,446.48 | $1,889.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.68 / $1,505.45 / $1,673.59
| Professional | | $1,258.68 | $1,505.45 | $1,673.59 |