- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $1,202.26
| Professional | | $776.25 | $851.14 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $4,073.80
| Professional | | $2,187.76 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $2,691.53
| Professional | | $831.76 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,412.54 / $3,019.95
| Professional | | $933.25 | $1,412.54 | $3,019.95 |