- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,857.20 / $3,972.91 / $6,190.54
| Professional | | $3,857.20 | $3,972.91 | $6,190.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,880.80 / $5,387.72 / $6,280.26
| Professional | | $3,880.80 | $5,387.72 | $6,280.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $4,321.80 / $4,321.80
| Facility | | $775.57 | $4,321.80 | $4,321.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.15 / $3,673.53 / $14,850.00
| Professional | | $724.15 | $3,673.53 | $14,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.59 / $1,024.59 / $1,024.59
| Professional | | $1,024.59 | $1,024.59 | $1,024.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.53 / $2,896.60 / $4,827.67
| Professional | | $1,963.53 | $2,896.60 | $4,827.67 |