- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.00 / $2,378.19 / $2,495.77
| Professional | | $960.00 | $2,378.19 | $2,495.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.50 / $2,491.92 / $3,082.72
| Facility | | $1,540.50 | $2,491.92 | $3,082.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.84 / $1,170.40 / $1,170.40
| Professional | | $994.84 | $1,170.40 | $1,170.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,878.74 / $5,060.64 / $5,081.35
| Facility | | $2,878.74 | $5,060.64 | $5,081.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,675.78 / $2,675.78 / $2,675.78
| Facility | | $2,675.78 | $2,675.78 | $2,675.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.95 / $1,235.75 / $1,505.63
| Professional | | $81.95 | $1,235.75 | $1,505.63 |