- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.10 / $915.18 / $3,313.64
| Professional | | $692.10 | $915.18 | $3,313.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.34 / $1,036.34 / $1,036.34
| Facility | | $1,036.34 | $1,036.34 | $1,036.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.83 / $1,023.16 / $1,036.34
| Professional | | $471.83 | $1,023.16 | $1,036.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.96 / $686.20 / $944.32
| Facility | | $510.96 | $686.20 | $944.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.91 / $1,023.16 / $1,358.70
| Professional | | $627.91 | $1,023.16 | $1,358.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.42 / $1,014.71 / $1,148.44
| Professional | | $811.42 | $1,014.71 | $1,148.44 |