- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $933.25 / $1,621.81
| Professional | | $812.83 | $933.25 | $1,621.81 |
- 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
- $1,819.70 / $2,754.23 / $3,235.94
| Professional | | $1,819.70 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $2,630.27
| Professional | | $1,071.52 | $1,621.81 | $2,630.27 |
- 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 / $1,659.59 / $3,388.44
| Professional | | $977.24 | $1,659.59 | $3,388.44 |