- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $1,122.02
| Professional | | $588.84 | $645.65 | $1,122.02 |
- 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
- $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
- $676.08 / $1,174.90 / $1,778.28
| Professional | | $676.08 | $1,174.90 | $1,778.28 |
- 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
- $575.44 / $1,122.02 / $2,454.71
| Professional | | $575.44 | $1,122.02 | $2,454.71 |