- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,995.26 / $3,715.35
| Professional | | $891.25 | $1,995.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,888.44 / $5,888.44
| Professional | | $3,630.78 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,089.30
| Professional | | $1,071.52 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,128.61 / $18,197.01
| Facility | | $3,467.37 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $4,677.35
| Professional | | $1,445.44 | $1,995.26 | $4,677.35 |