- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.84 / $1,442.31 / $2,415.41
| Professional | | $1,153.84 | $1,442.31 | $2,415.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $651.19 / $908.71 / $1,528.03
| Facility | | $651.19 | $908.71 | $1,528.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.00 / $2,562.42 / $2,562.42
| Professional | | $955.00 | $2,562.42 | $2,562.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $955.00 / $955.00 / $955.00
| Facility | | $955.00 | $955.00 | $955.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.00 / $1,057.07 / $1,111.53
| Professional | | $741.00 | $1,057.07 | $1,111.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $729.90 / $1,439.80
| Professional | | $4.00 | $729.90 | $1,439.80 |