- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,513.56
| Professional | | $630.96 | $707.95 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,412.54
| Facility | | $831.76 | $831.76 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $1,258.93
| Professional | | $616.60 | $616.60 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $1,000.00
| Facility | | $478.63 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $630.96 / $954.99
| Professional | | $562.34 | $630.96 | $954.99 |