- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $537.03 / $1,318.26
| Professional | | $478.63 | $537.03 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $1,659.59
| Professional | | $1,148.15 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $891.25 / $1,288.25
| Professional | | $707.95 | $891.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $3,235.94
| Facility | | $794.33 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,023.29 / $1,862.09
| Professional | | $602.56 | $1,023.29 | $1,862.09 |