- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $2,511.89
| Professional | | $912.01 | $1,023.29 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $3,162.28
| Professional | | $1,819.70 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $2,454.71
| Professional | | $1,380.38 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,168.69 / $14,125.38
| Facility | | $2,951.21 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $3,801.89
| Professional | | $1,230.27 | $1,949.84 | $3,801.89 |