- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.35 / $1,174.16 / $2,214.71
| Professional | | $875.35 | $1,174.16 | $2,214.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.99 / $2,217.64 / $3,059.25
| Professional | | $1,884.99 | $2,217.64 | $3,059.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.89 / $2,427.89 / $2,610.76
| Professional | | $2,427.89 | $2,427.89 | $2,610.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.42 / $1,765.42 / $1,765.42
| Professional | | $1,765.42 | $1,765.42 | $1,765.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.34 / $1,481.52 / $2,118.90
| Professional | | $1,099.34 | $1,481.52 | $2,118.90 |