- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $5,623.41
| Professional | | $2,290.87 | $2,630.27 | $5,623.41 |
- 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
- $3,019.95 / $3,090.30 / $5,623.41
| Professional | | $3,019.95 | $3,090.30 | $5,623.41 |
- 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
- $2,818.38 / $4,466.84 / $8,128.31
| Professional | | $2,818.38 | $4,466.84 | $8,128.31 |