- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $977.24 / $1,659.59
| Professional | | $870.96 | $977.24 | $1,659.59 |
- 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
- $1,862.09 / $2,818.38 / $3,388.44
| Professional | | $1,862.09 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $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
- $977.24 / $1,698.24 / $3,548.13
| Professional | | $977.24 | $1,698.24 | $3,548.13 |