- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,691.53 / $5,754.40
| Professional | | $2,344.23 | $2,691.53 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,025.60 / $7,244.36
| Professional | | $5,370.32 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,548.13 / $5,754.40
| Professional | | $3,388.44 | $3,548.13 | $5,754.40 |
- 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 / $4,570.88 / $9,332.54
| Professional | | $2,630.27 | $4,570.88 | $9,332.54 |