- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $575.44 / $1,023.29
| Professional | | $524.81 | $575.44 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $2,041.74
| Professional | | $1,348.96 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $1,621.81
| Professional | | $660.69 | $1,047.13 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,168.69 / $14,125.38
| Facility | | $2,754.23 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,023.29 / $2,187.76
| Professional | | $616.60 | $1,023.29 | $2,187.76 |