- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $2,041.74
| Professional | | $912.01 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $4,073.80
| Professional | | $2,238.72 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $3,162.28
| Professional | | $1,202.26 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $25,703.96
| Facility | | $6,918.31 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $3,890.45
| Professional | | $1,096.48 | $1,995.26 | $3,890.45 |