- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $741.31 / $1,318.26
| Professional | | $691.83 | $741.31 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,137.96 / $2,570.40
| Professional | | $1,412.54 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,041.74
| Professional | | $831.76 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $10,471.29
| Facility | | $2,630.27 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $2,754.23
| Professional | | $794.33 | $1,318.26 | $2,754.23 |