- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $954.99 / $1,698.24
| Professional | | $891.25 | $954.99 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,801.89 / $3,801.89
| Professional | | $2,344.23 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $2,398.83
| Professional | | $1,047.13 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,495.41 / $18,197.01
| Facility | | $5,128.61 | $5,495.41 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,737.80 / $3,388.44
| Professional | | $977.24 | $1,737.80 | $3,388.44 |