- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,174.90
| Professional | | $575.44 | $691.83 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $2,398.83
| Professional | | $1,318.26 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,949.84
| Professional | | $794.33 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,754.23 / $5,370.32
| Facility | | $1,288.25 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,174.90 / $2,398.83
| Professional | | $691.83 | $1,174.90 | $2,398.83 |