- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,023.29 / $1,778.28
| Professional | | $933.25 | $1,023.29 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,073.80 / $4,786.30
| Professional | | $2,630.27 | $4,073.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,949.84
| Professional | | $812.83 | $1,148.15 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,737.80 / $2,951.21
| Professional | | $933.25 | $1,737.80 | $2,951.21 |