- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.09 / $1,927.40 / $2,148.94
| Professional | | $1,883.09 | $1,927.40 | $2,148.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.26 / $2,245.17 / $4,363.54
| Professional | | $336.26 | $2,245.17 | $4,363.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,883.09 / $1,991.86 / $4,968.03
| Facility | | $1,883.09 | $1,991.86 | $4,968.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $11,032.69
| Professional | | $930.47 | $1,329.24 | $11,032.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $2,423.65
| Professional | | $930.47 | $1,329.24 | $2,423.65 |