- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.86 / $910.78 / $3,584.55
| Professional | | $680.86 | $910.78 | $3,584.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.48 / $1,069.48 / $1,069.48
| Facility | | $1,069.48 | $1,069.48 | $1,069.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.44 / $1,069.48 / $1,093.00
| Professional | | $615.44 | $1,069.48 | $1,093.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.59 / $726.81 / $1,069.48
| Facility | | $528.59 | $726.81 | $1,069.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.76 / $1,069.48 / $1,416.80
| Professional | | $654.76 | $1,069.48 | $1,416.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.58 / $1,124.48 / $1,272.67
| Professional | | $972.58 | $1,124.48 | $1,272.67 |