- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $954.99 / $1,230.27
| Professional | | $707.95 | $954.99 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,288.25
| Facility | | $1,071.52 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Professional | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $4,677.35
| Professional | | $794.33 | $1,122.02 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $1,348.96
| Professional | | $602.56 | $891.25 | $1,348.96 |