- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.40 / $2,427.09 / $3,246.23
| Professional | | $2,275.40 | $2,427.09 | $3,246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,695.30 / $3,695.30 / $4,427.39
| Professional | | $3,695.30 | $3,695.30 | $4,427.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,166.17 / $2,548.44 / $4,399.10
| Facility | | $2,166.17 | $2,548.44 | $4,399.10 |
- 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 / $3,033.86
| Professional | | $1,274.22 | $1,274.22 | $3,033.86 |