- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,698.24 / $3,090.30
| Professional | | $1,548.82 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,888.44 / $5,888.44
| Professional | | $3,890.45 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,162.28 / $4,677.35
| Professional | | $2,089.30 | $3,162.28 | $4,677.35 |
- 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
- $1,905.46 / $3,090.30 / $6,606.93
| Professional | | $1,905.46 | $3,090.30 | $6,606.93 |