- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $724.44 / $1,288.25
| Professional | | $660.69 | $724.44 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $2,511.89
| Professional | | $1,698.24 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,041.74
| Professional | | $870.96 | $1,288.25 | $2,041.74 |
- 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
- $776.25 / $1,288.25 / $2,754.23
| Professional | | $776.25 | $1,288.25 | $2,754.23 |