- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $1,318.26
| Professional | | $676.08 | $831.76 | $1,318.26 |
- 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
- $1,819.70 / $2,691.53 / $2,754.23
| Professional | | $1,819.70 | $2,691.53 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,445.44 / $2,754.23
| Professional | | $691.83 | $1,445.44 | $2,754.23 |
- 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
- $645.65 / $1,412.54 / $2,754.23
| Professional | | $645.65 | $1,412.54 | $2,754.23 |