- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.10 / $1,357.53 / $5,251.41
| Professional | | $979.10 | $1,357.53 | $5,251.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,572.14 / $1,572.14 / $1,572.14
| Facility | | $1,572.14 | $1,572.14 | $1,572.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.10 / $1,572.14 / $1,704.10
| Professional | | $869.10 | $1,572.14 | $1,704.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $770.44 / $1,059.35 / $1,572.14
| Facility | | $770.44 | $1,059.35 | $1,572.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.56 / $1,572.14 / $2,072.00
| Professional | | $957.56 | $1,572.14 | $2,072.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.97 / $1,662.28 / $1,935.78
| Professional | | $1,400.97 | $1,662.28 | $1,935.78 |