- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.33 / $945.26 / $3,301.79
| Professional | | $700.33 | $945.26 | $3,301.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.76 / $1,044.76 / $1,044.76
| Facility | | $1,044.76 | $1,044.76 | $1,044.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.34 / $989.40 / $1,044.76
| Professional | | $398.34 | $989.40 | $1,044.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.18 / $701.49 / $1,044.76
| Facility | | $510.18 | $701.49 | $1,044.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.17 / $999.47 / $1,387.40
| Professional | | $641.17 | $999.47 | $1,387.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.00 / $981.37 / $1,126.26
| Professional | | $765.00 | $981.37 | $1,126.26 |