- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $3,715.35
| Professional | | $1,513.56 | $1,737.80 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,786.30 / $4,786.30
| Professional | | $4,168.69 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,715.35
| Professional | | $2,187.76 | $2,187.76 | $3,715.35 |
- 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
- $1,862.09 / $2,951.21 / $5,754.40
| Professional | | $1,862.09 | $2,951.21 | $5,754.40 |