- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $1,513.56
| Professional | | $776.25 | $912.01 | $1,513.56 |
- 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
- $1,698.24 / $2,570.40 / $3,090.30
| Professional | | $1,698.24 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,511.89
| Professional | | $1,096.48 | $1,548.82 | $2,511.89 |
- 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
- $954.99 / $1,584.89 / $3,235.94
| Professional | | $954.99 | $1,584.89 | $3,235.94 |