- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $1,584.89
| Professional | | $831.76 | $912.01 | $1,584.89 |
- 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
- $1,737.80 / $2,630.27 / $3,162.28
| Professional | | $1,737.80 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,511.89
| Professional | | $1,096.48 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $3,548.13
| Professional | | $954.99 | $1,621.81 | $3,548.13 |