- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.65 / $1,292.51 / $6,751.50
| Professional | | $729.65 | $1,292.51 | $6,751.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.44 / $1,757.44 / $1,757.44
| Facility | | $1,757.44 | $1,757.44 | $1,757.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.36 / $1,507.97 / $2,358.83
| Professional | | $1,206.36 | $1,507.97 | $2,358.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.44 / $1,757.44 / $1,757.44
| Facility | | $1,757.44 | $1,757.44 | $1,757.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.50 / $1,206.36 / $2,358.83
| Professional | | $682.50 | $1,206.36 | $2,358.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.64 / $1,042.34 / $2,425.92
| Professional | | $458.64 | $1,042.34 | $2,425.92 |