- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.88 / $979.00 / $3,429.83
| Professional | | $726.88 | $979.00 | $3,429.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.61 / $1,082.61 / $1,082.61
| Facility | | $1,082.61 | $1,082.61 | $1,082.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.39 / $1,000.46 / $1,082.61
| Professional | | $519.39 | $1,000.46 | $1,082.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.26 / $727.74 / $1,082.61
| Facility | | $529.26 | $727.74 | $1,082.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.79 / $1,036.21 / $1,438.50
| Professional | | $664.79 | $1,036.21 | $1,438.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.45 / $1,016.95 / $1,171.90
| Professional | | $870.45 | $1,016.95 | $1,171.90 |