- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,047.13 / $1,819.70
| Professional | | $954.99 | $1,047.13 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,011.87 / $5,011.87
| Professional | | $3,235.94 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $2,089.30
| Professional | | $933.25 | $1,288.25 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $18,197.01
| Facility | | $2,754.23 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,778.28 / $3,235.94
| Professional | | $1,023.29 | $1,778.28 | $3,235.94 |