- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.03 / $997.28 / $3,710.45
| Professional | | $756.03 | $997.28 | $3,710.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.15 / $1,134.15 / $1,134.15
| Facility | | $1,134.15 | $1,134.15 | $1,134.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.57 / $1,134.15 / $1,189.03
| Professional | | $521.57 | $1,134.15 | $1,189.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $561.70 / $772.34 / $1,134.15
| Facility | | $561.70 | $772.34 | $1,134.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.59 / $1,134.15 / $1,477.00
| Professional | | $682.59 | $1,134.15 | $1,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.21 / $1,144.08 / $1,307.52
| Professional | | $960.21 | $1,144.08 | $1,307.52 |