- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $691.83 / $2,398.83
| Professional | | $457.09 | $691.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $2,691.53
| Professional | | $794.33 | $794.33 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $870.96 / $2,691.53
| Professional | | $831.76 | $870.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,548.82
| Professional | | $660.69 | $891.25 | $1,548.82 |