- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $467.74 / $851.14
| Professional | | $436.52 | $467.74 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $1,659.59
| Professional | | $1,096.48 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $831.76 / $1,318.26
| Professional | | $645.65 | $831.76 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $5,370.32
| Facility | | $1,288.25 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $933.25 / $1,737.80
| Professional | | $588.84 | $933.25 | $1,737.80 |