- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.35 / $1,180.00 / $1,248.63
| Professional | | $875.35 | $1,180.00 | $1,248.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.82 / $1,501.82 / $2,412.10
| Professional | | $1,501.82 | $1,501.82 | $2,412.10 |
- 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 / $2,217.64
| Professional | | $1,884.99 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.71 / $1,357.94 / $2,263.23
| Professional | | $933.71 | $1,357.94 | $2,263.23 |