- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $602.56 / $1,318.26
| Professional | | $457.09 | $602.56 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,288.25
| Facility | | $1,023.29 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $741.31 / $1,122.02
| Professional | | $489.78 | $741.31 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $758.58 / $954.99
| Professional | | $575.44 | $758.58 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $707.95 / $1,318.26
| Professional | | $602.56 | $707.95 | $1,318.26 |