- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,258.93 / $2,238.72
| Professional | | $1,174.90 | $1,258.93 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,466.84 / $4,466.84
| Professional | | $2,951.21 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,344.23 / $3,548.13
| Professional | | $1,548.82 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $14,125.38
| Facility | | $4,168.69 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $4,897.79
| Professional | | $1,412.54 | $2,290.87 | $4,897.79 |