- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.21 / $2,099.67 / $2,678.48
| Professional | | $1,615.21 | $2,099.67 | $2,678.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,341.25 / $3,573.24 / $3,573.24
| Professional | | $3,341.25 | $3,573.24 | $3,573.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.99 / $2,053.86 / $2,416.31
| Professional | | $257.99 | $2,053.86 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.59 / $1,511.44 / $2,390.40
| Professional | | $1,228.59 | $1,511.44 | $2,390.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.84 / $3,543.05 / $3,543.05
| Professional | | $2,583.84 | $3,543.05 | $3,543.05 |