- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $3,467.37
| Professional | | $1,412.54 | $1,621.81 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,466.84 / $4,466.84
| Professional | | $3,981.07 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $3,548.13
| Professional | | $2,137.96 | $2,238.72 | $3,548.13 |
- 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 / $2,754.23 / $5,888.44
| Professional | | $1,862.09 | $2,754.23 | $5,888.44 |