- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,089.30 / $4,466.84
| Professional | | $1,819.70 | $2,089.30 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,786.30 / $5,754.40
| Professional | | $4,265.80 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $4,466.84
| Professional | | $2,691.53 | $2,818.38 | $4,466.84 |
- 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
- $2,454.71 / $3,630.78 / $7,413.10
| Professional | | $2,454.71 | $3,630.78 | $7,413.10 |