- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $758.58 / $1,288.25
| Professional | | $707.95 | $758.58 | $1,288.25 |
- 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
- $1,698.24 / $2,570.40 / $2,570.40
| Professional | | $1,698.24 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,412.54 / $2,089.30
| Professional | | $891.25 | $1,412.54 | $2,089.30 |
- 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
- $812.83 / $1,318.26 / $2,884.03
| Professional | | $812.83 | $1,318.26 | $2,884.03 |