- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $3,019.95 / $13,803.84
| Professional | | $691.83 | $3,019.95 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $15,135.61
| Professional | | $1,380.38 | $2,398.83 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $14,125.38
| Professional | | $1,047.13 | $1,778.28 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,511.38 / $26,915.35
| Facility | | $8,317.64 | $8,511.38 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,162.28 / $19,054.61
| Professional | | $1,348.96 | $3,162.28 | $19,054.61 |