- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $870.96 / $1,548.82
| Professional | | $794.33 | $870.96 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,090.30 / $3,090.30
| Professional | | $2,041.74 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,454.71
| Professional | | $1,202.26 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $18,197.01
| Facility | | $5,128.61 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $3,467.37
| Professional | | $1,047.13 | $1,584.89 | $3,467.37 |