- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,238.72 / $2,570.40
| Professional | | $457.09 | $2,238.72 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $8,709.64
| Professional | | $3,467.37 | $4,265.80 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- 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
- $1,148.15 / $1,148.15 / $2,754.23
| Professional | | $1,148.15 | $1,148.15 | $2,754.23 |