- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $588.84 / $1,348.96
| Professional | | $338.84 | $588.84 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,071.52 / $1,621.81
| Professional | | $645.65 | $1,071.52 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $758.58 / $1,445.44
| Professional | | $457.09 | $758.58 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $5,370.32
| Facility | | $1,288.25 | $1,380.38 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $831.76 / $1,659.59
| Professional | | $407.38 | $831.76 | $1,659.59 |