- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,398.83
| Professional | | $741.31 | $1,047.13 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,495.41 / $5,495.41
| Professional | | $3,388.44 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,659.59
| Professional | | $851.14 | $1,148.15 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,168.69 / $14,125.38
| Facility | | $3,235.94 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,698.24 / $2,818.38
| Professional | | $891.25 | $1,698.24 | $2,818.38 |