- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,122.02 / $1,949.84
| Professional | | $1,023.29 | $1,122.02 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,890.45 / $3,890.45
| Professional | | $2,570.40 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $3,090.30
| Professional | | $1,348.96 | $2,041.74 | $3,090.30 |
- 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
- $1,230.27 / $1,995.26 / $4,265.80
| Professional | | $1,230.27 | $1,995.26 | $4,265.80 |