- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.14 / $645.94 / $1,186.93
| Professional | | $514.14 | $645.94 | $1,186.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.82 / $1,198.82 / $1,198.82
| Facility | | $1,198.82 | $1,198.82 | $1,198.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.32 / $853.69 / $1,849.74
| Professional | | $662.32 | $853.69 | $1,849.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.14 / $873.83 / $1,518.47
| Facility | | $720.14 | $873.83 | $1,518.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.49 / $1,418.13 / $2,049.48
| Professional | | $799.49 | $1,418.13 | $2,049.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.00 / $1,056.71 / $1,228.50
| Professional | | $915.00 | $1,056.71 | $1,228.50 |