- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $3,162.28
| Professional | | $1,288.25 | $1,479.11 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,073.80 / $4,073.80
| Professional | | $3,630.78 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $3,162.28
| Professional | | $1,905.46 | $2,041.74 | $3,162.28 |
- 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
- $1,659.59 / $2,511.89 / $5,370.32
| Professional | | $1,659.59 | $2,511.89 | $5,370.32 |