- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $1,148.15
| Professional | | $645.65 | $724.44 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,479.11
| Facility | | $831.76 | $831.76 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,318.26
| Professional | | $602.56 | $602.56 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $1,047.13
| Facility | | $501.19 | $645.65 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $660.69 / $1,000.00
| Professional | | $588.84 | $660.69 | $1,000.00 |