- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $676.08 / $1,148.15
| Professional | | $562.34 | $676.08 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,949.84
| Facility | | $812.83 | $812.83 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,288.25
| Professional | | $691.83 | $691.83 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $851.14 / $1,047.13
| Facility | | $489.78 | $851.14 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $1,000.00
| Professional | | $588.84 | $645.65 | $1,000.00 |