- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $831.76 / $2,089.30
| Professional | | $776.25 | $831.76 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,311.31 / $3,311.31
| Professional | | $1,621.81 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $1,995.26
| Professional | | $1,096.48 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $18,197.01
| Facility | | $2,754.23 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,659.59 / $2,951.21
| Professional | | $977.24 | $1,659.59 | $2,951.21 |