- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.09 / $2,639.46 / $3,246.23
| Professional | | $2,427.09 | $2,639.46 | $3,246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,792.33 / $3,792.33 / $3,792.33
| Professional | | $3,792.33 | $3,792.33 | $3,792.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,427.09 / $3,033.86 / $4,081.48
| Facility | | $2,427.09 | $3,033.86 | $4,081.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.24 / $1,820.32 / $15,108.62
| Professional | | $1,365.24 | $1,820.32 | $15,108.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.24 / $1,820.32 / $4,550.79
| Professional | | $1,365.24 | $1,820.32 | $4,550.79 |