- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.84 / $714.02 / $1,322.54
| Professional | | $519.84 | $714.02 | $1,322.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.07 / $886.07 / $2,090.63
| Professional | | $886.07 | $886.07 | $2,090.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.75 / $726.75 / $726.75
| Professional | | $726.75 | $726.75 | $726.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.56 / $1,098.56 / $1,098.56
| Professional | | $1,098.56 | $1,098.56 | $1,098.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.71 / $832.00 / $1,309.26
| Professional | | $597.71 | $832.00 | $1,309.26 |