- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.54 / $807.15 / $870.86
| Professional | | $641.54 | $807.15 | $870.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,076.00 / $2,803.91 / $3,319.50
| Facility | | $2,076.00 | $2,803.91 | $3,319.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.18 / $959.04 / $1,327.82
| Professional | | $815.18 | $959.04 | $1,327.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.85 / $1,038.85 / $1,038.85
| Facility | | $1,038.85 | $1,038.85 | $1,038.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.37 / $1,038.85 / $1,038.85
| Professional | | $758.37 | $1,038.85 | $1,038.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.24 / $732.53 / $1,220.88
| Professional | | $568.24 | $732.53 | $1,220.88 |