- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,041.74 / $4,466.84
| Professional | | $1,778.28 | $2,041.74 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,786.30 / $5,754.40
| Professional | | $4,168.69 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,570.88
| Professional | | $2,398.83 | $2,398.83 | $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
- $2,187.76 / $3,548.13 / $6,456.54
| Professional | | $2,187.76 | $3,548.13 | $6,456.54 |