- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.07 / $1,063.69 / $5,208.22
| Professional | | $943.07 | $1,063.69 | $5,208.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.76 / $1,584.76 / $1,584.76
| Facility | | $1,584.76 | $1,584.76 | $1,584.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.06 / $1,584.76 / $1,671.50
| Professional | | $845.06 | $1,584.76 | $1,671.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.01 / $1,079.39 / $1,584.76
| Facility | | $785.01 | $1,079.39 | $1,584.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.53 / $1,584.76 / $2,074.10
| Professional | | $958.53 | $1,584.76 | $2,074.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.27 / $1,633.05 / $1,842.56
| Professional | | $1,390.27 | $1,633.05 | $1,842.56 |