- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $3,162.28
| Professional | | $1,698.24 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,413.10 / $8,912.51
| Professional | | $4,786.30 | $7,413.10 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $6,025.60
| Professional | | $1,862.09 | $3,090.30 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,235.94 / $6,760.83
| Professional | | $2,041.74 | $3,235.94 | $6,760.83 |