- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.97 / $1,198.00 / $1,510.53
| Professional | | $295.97 | $1,198.00 | $1,510.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,199.79 / $4,199.79 / $4,537.22
| Facility | | $4,199.79 | $4,199.79 | $4,537.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.17 / $470.59 / $1,008.35
| Professional | | $291.17 | $470.59 | $1,008.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.15 / $475.73 / $1,008.35
| Professional | | $376.15 | $475.73 | $1,008.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.51 / $407.68 / $1,237.64
| Professional | | $379.51 | $407.68 | $1,237.64 |