- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $707.95 / $1,230.27
| Professional | | $645.65 | $707.95 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $2,454.71
| Professional | | $1,348.96 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $1,949.84
| Professional | | $758.58 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $5,370.32
| Facility | | $1,288.25 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,258.93 / $2,691.53
| Professional | | $630.96 | $1,258.93 | $2,691.53 |