- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $3,019.95
| Professional | | $1,202.26 | $1,348.96 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,890.45 / $3,890.45
| Professional | | $2,691.53 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $2,884.03
| Professional | | $1,659.59 | $2,041.74 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,888.44 / $14,125.38
| Facility | | $4,168.69 | $5,888.44 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $4,365.16
| Professional | | $1,445.44 | $2,398.83 | $4,365.16 |