- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $2,951.21
| Professional | | $1,412.54 | $1,698.24 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,897.79 / $5,888.44
| Professional | | $3,235.94 | $4,897.79 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $4,677.35
| Professional | | $1,995.26 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $18,197.01
| Facility | | $5,128.61 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,090.30 / $6,165.95
| Professional | | $1,819.70 | $3,090.30 | $6,165.95 |