- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $575.44 / $1,071.52
| Professional | | $371.54 | $575.44 | $1,071.52 |
- 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
- $851.14 / $1,288.25 / $1,737.80
| Professional | | $851.14 | $1,288.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $933.25 / $1,698.24
| Professional | | $575.44 | $933.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $891.25 / $1,905.46
| Professional | | $512.86 | $891.25 | $1,905.46 |