- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.16 / $677.23 / $3,574.64
| Professional | | $567.16 | $677.23 | $3,574.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.08 / $1,102.08 / $1,102.08
| Facility | | $1,102.08 | $1,102.08 | $1,102.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.83 / $1,102.08 / $1,943.38
| Professional | | $644.83 | $1,102.08 | $1,943.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.18 / $936.92 / $1,239.70
| Facility | | $681.18 | $936.92 | $1,239.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.55 / $1,122.08 / $1,869.78
| Professional | | $685.55 | $1,122.08 | $1,869.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.10 / $1,148.16 / $1,509.41
| Professional | | $946.10 | $1,148.16 | $1,509.41 |