- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $5,370.32
| Professional | | $2,137.96 | $2,398.83 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,754.40 / $6,918.31
| Professional | | $3,981.07 | $5,754.40 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,630.78 / $5,128.61
| Professional | | $2,818.38 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,265.80 / $7,585.78
| Professional | | $2,398.83 | $4,265.80 | $7,585.78 |