- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $4,168.69
| Professional | | $1,659.59 | $1,778.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,466.84 / $5,370.32
| Professional | | $3,090.30 | $4,466.84 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $3,801.89
| Professional | | $2,238.72 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,311.31 / $6,165.95
| Professional | | $2,238.72 | $3,311.31 | $6,165.95 |