- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.23 / $1,267.05 / $4,765.56
| Professional | | $956.23 | $1,267.05 | $4,765.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.97 / $1,425.97 / $1,425.97
| Facility | | $1,425.97 | $1,425.97 | $1,425.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.90 / $1,425.97 / $1,503.89
| Professional | | $769.90 | $1,425.97 | $1,503.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.42 / $971.32 / $1,425.97
| Facility | | $706.42 | $971.32 | $1,425.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.36 / $1,425.97 / $1,872.50
| Professional | | $865.36 | $1,425.97 | $1,872.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.98 / $1,490.60 / $1,663.86
| Professional | | $1,229.98 | $1,490.60 | $1,663.86 |