- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.71 / $893.41 / $3,314.54
| Professional | | $675.71 | $893.41 | $3,314.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.32 / $1,015.32 / $1,015.32
| Facility | | $1,015.32 | $1,015.32 | $1,015.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.59 / $969.03 / $1,015.32
| Professional | | $518.59 | $969.03 | $1,015.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.62 / $692.48 / $1,015.32
| Facility | | $503.62 | $692.48 | $1,015.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.77 / $969.03 / $1,321.60
| Professional | | $610.77 | $969.03 | $1,321.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.80 / $1,020.87 / $1,166.71
| Professional | | $856.80 | $1,020.87 | $1,166.71 |