- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.12 / $1,255.54 / $4,672.97
| Professional | | $954.12 | $1,255.54 | $4,672.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.02 / $1,427.02 / $1,427.02
| Facility | | $1,427.02 | $1,427.02 | $1,427.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.81 / $1,427.02 / $1,495.74
| Professional | | $741.81 | $1,427.02 | $1,495.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.81 / $971.86 / $1,427.02
| Facility | | $706.81 | $971.86 | $1,427.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.83 / $1,427.02 / $1,862.70
| Professional | | $860.83 | $1,427.02 | $1,862.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.55 / $1,469.46 / $1,649.92
| Professional | | $1,111.55 | $1,469.46 | $1,649.92 |