- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.46 / $2,313.48 / $3,762.88
| Professional | | $1,921.46 | $2,313.48 | $3,762.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.82 / $929.22 / $1,373.38
| Facility | | $656.82 | $929.22 | $1,373.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Professional | | $821.00 | $821.00 | $821.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.40 / $901.80 / $1,098.00
| Professional | | $857.40 | $901.80 | $1,098.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,443.22 / $12,981.45 / $26,542.00
| Facility | | $1,443.22 | $12,981.45 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.76 / $3,018.40 / $3,018.40
| Professional | | $2,790.76 | $3,018.40 | $3,018.40 |