- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.24 / $1,883.09 / $1,883.09
| Professional | | $1,473.24 | $1,883.09 | $1,883.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.49 / $2,114.38 / $2,378.67
| Professional | | $1,321.49 | $2,114.38 | $2,378.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.32 / $2,215.40 / $4,078.47
| Facility | | $1,484.32 | $2,215.40 | $4,078.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $930.47 / $11,032.69
| Professional | | $930.47 | $930.47 | $11,032.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $930.47 / $1,329.24
| Professional | | $930.47 | $930.47 | $1,329.24 |