- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.98 / $1,171.41 / $4,354.26
| Professional | | $888.98 | $1,171.41 | $4,354.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.38 / $1,332.38 / $1,332.38
| Facility | | $1,332.38 | $1,332.38 | $1,332.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.37 / $1,332.38 / $1,390.98
| Professional | | $686.37 | $1,332.38 | $1,390.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $659.83 / $907.27 / $1,332.38
| Facility | | $659.83 | $907.27 | $1,332.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.60 / $1,332.38 / $1,736.70
| Professional | | $802.60 | $1,332.38 | $1,736.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.33 / $1,346.57 / $1,574.09
| Professional | | $1,220.33 | $1,346.57 | $1,574.09 |