- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $933.25 / $2,511.89
| Professional | | $891.25 | $933.25 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $4,073.80
| Professional | | $2,089.30 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $2,454.71
| Professional | | $1,071.52 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $25,703.96
| Facility | | $6,918.31 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $2,041.74 / $3,235.94
| Professional | | $954.99 | $2,041.74 | $3,235.94 |