- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,445.44 / $3,467.37
| Professional | | $1,412.54 | $1,445.44 | $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
- $2,041.74 / $2,187.76 / $3,630.78
| Professional | | $2,041.74 | $2,187.76 | $3,630.78 |
- 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
- $2,089.30 / $2,818.38 / $5,495.41
| Professional | | $2,089.30 | $2,818.38 | $5,495.41 |