- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.23 / $1,261.16 / $4,497.39
| Professional | | $945.23 | $1,261.16 | $4,497.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,401.26 / $1,401.26 / $1,401.26
| Facility | | $1,401.26 | $1,401.26 | $1,401.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.48 / $1,350.24 / $1,401.26
| Professional | | $693.48 | $1,350.24 | $1,401.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $687.25 / $944.97 / $1,401.26
| Facility | | $687.25 | $944.97 | $1,401.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.19 / $1,350.24 / $1,861.30
| Professional | | $860.19 | $1,350.24 | $1,861.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.15 / $1,365.12 / $1,564.80
| Professional | | $1,149.15 | $1,365.12 | $1,564.80 |