- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $5,495.41
| Professional | | $2,238.72 | $2,570.40 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,888.44 / $7,079.46
| Professional | | $5,248.07 | $5,888.44 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $5,495.41
| Professional | | $3,311.31 | $3,311.31 | $5,495.41 |
- 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
- $2,691.53 / $4,466.84 / $8,709.64
| Professional | | $2,691.53 | $4,466.84 | $8,709.64 |