- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.03 / $2,990.82 / $3,095.15
| Professional | | $2,508.03 | $2,990.82 | $3,095.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,504.98 / $2,722.81 / $2,722.81
| Professional | | $2,504.98 | $2,722.81 | $2,722.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $4,080.53
| Facility | | $2,569.13 | $2,569.13 | $4,080.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.60 / $2,183.76 / $6,060.94
| Professional | | $295.60 | $2,183.76 | $6,060.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.99 / $198.56 / $1,687.74
| Professional | | $122.99 | $198.56 | $1,687.74 |