- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.52 / $2,275.40 / $2,578.78
| Professional | | $2,017.52 | $2,275.40 | $2,578.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.48 / $2,555.96 / $2,875.46
| Professional | | $1,597.48 | $2,555.96 | $2,875.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,032.69 / $3,033.86 / $5,775.59
| Facility | | $2,032.69 | $3,033.86 | $5,775.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,274.22 / $15,108.62
| Professional | | $1,274.22 | $1,274.22 | $15,108.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,274.22 / $1,820.32
| Professional | | $1,274.22 | $1,274.22 | $1,820.32 |