- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $831.76 / $1,995.26
| Professional | | $316.23 | $831.76 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,548.13 / $4,265.80
| Professional | | $2,290.87 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $14,125.38
| Facility | | $4,168.69 | $5,128.61 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $602.56 / $2,630.27
| Professional | | $331.13 | $602.56 | $2,630.27 |