- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.21 / $726.46 / $3,610.00
| Professional | | $552.21 | $726.46 | $3,610.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,193.04 / $1,193.04 / $1,193.04
| Facility | | $1,193.04 | $1,193.04 | $1,193.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.39 / $679.39 / $1,193.04
| Professional | | $679.39 | $679.39 | $1,193.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.03 / $910.13 / $1,252.98
| Facility | | $679.03 | $910.13 | $1,252.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.85 / $1,214.82 / $1,922.98
| Professional | | $728.85 | $1,214.82 | $1,922.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.75 / $1,149.69 / $1,411.82
| Professional | | $930.75 | $1,149.69 | $1,411.82 |