- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $676.08 / $1,202.26
| Professional | | $616.60 | $676.08 | $1,202.26 |
- 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
- $1,584.89 / $2,398.83 / $2,398.83
| Professional | | $1,584.89 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $1,905.46
| Professional | | $776.25 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $18,197.01
| Facility | | $2,754.23 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $2,570.40
| Professional | | $724.44 | $1,202.26 | $2,570.40 |