- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.06 / $221.90 / $1,119.82
| Professional | | $190.06 | $221.90 | $1,119.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.23 / $2,448.23 / $3,040.81
| Facility | | $2,448.23 | $2,448.23 | $3,040.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.18 / $1,296.18 / $3,081.87
| Professional | | $1,296.18 | $1,296.18 | $3,081.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.59 / $1,199.96 / $3,081.87
| Professional | | $241.59 | $1,199.96 | $3,081.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.59 / $1,199.96 / $3,081.87
| Professional | | $241.59 | $1,199.96 | $3,081.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.19 / $1,263.26 / $3,782.66
| Professional | | $859.19 | $1,263.26 | $3,782.66 |