- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $724.44 / $1,230.27
| Professional | | $630.96 | $724.44 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $2,238.72
| Professional | | $1,230.27 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,348.96 / $2,187.76
| Professional | | $758.58 | $1,348.96 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $5,370.32
| Facility | | $1,258.93 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $2,454.71
| Professional | | $707.95 | $1,258.93 | $2,454.71 |