- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.64 / $897.75 / $3,339.79
| Professional | | $680.64 | $897.75 | $3,339.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.73 / $1,023.73 / $1,023.73
| Facility | | $1,023.73 | $1,023.73 | $1,023.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.49 / $1,023.73 / $1,073.21
| Professional | | $530.49 | $1,023.73 | $1,073.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.77 / $699.56 / $1,151.15
| Facility | | $508.77 | $699.56 | $1,151.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.65 / $1,023.73 / $1,330.00
| Professional | | $614.65 | $1,023.73 | $1,330.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.89 / $805.89 / $6,489.22
| Facility | | $805.89 | $805.89 | $6,489.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.65 / $1,045.75 / $1,164.93
| Professional | | $643.65 | $1,045.75 | $1,164.93 |