- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,584.89 / $3,715.35
| Professional | | $1,513.56 | $1,584.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,981.07 / $4,786.30
| Professional | | $3,548.13 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,691.53 / $4,570.88
| Professional | | $2,511.89 | $2,691.53 | $4,570.88 |
- 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
- $2,630.27 / $3,090.30 / $7,244.36
| Professional | | $2,630.27 | $3,090.30 | $7,244.36 |