- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.49 / $1,411.07 / $5,265.45
| Professional | | $1,075.49 | $1,411.07 | $5,265.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.64 / $1,602.64 / $1,602.64
| Facility | | $1,602.64 | $1,602.64 | $1,602.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.44 / $1,602.64 / $1,689.55
| Professional | | $841.44 | $1,602.64 | $1,689.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.30 / $1,092.16 / $1,602.64
| Facility | | $794.30 | $1,092.16 | $1,602.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.21 / $1,602.64 / $2,097.19
| Professional | | $969.21 | $1,602.64 | $2,097.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.70 / $1,672.72 / $2,100.42
| Professional | | $1,367.70 | $1,672.72 | $2,100.42 |