- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,715.35
| Professional | | $1,737.80 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,165.95 / $7,244.36
| Professional | | $4,073.80 | $6,165.95 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,630.78 / $5,754.40
| Professional | | $2,454.71 | $3,630.78 | $5,754.40 |
- 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
- $2,187.76 / $3,801.89 / $7,585.78
| Professional | | $2,187.76 | $3,801.89 | $7,585.78 |