- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,737.80 / $4,168.69
| Professional | | $1,698.24 | $1,737.80 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,370.32 / $5,370.32
| Professional | | $4,786.30 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $4,265.80
| Professional | | $2,454.71 | $2,630.27 | $4,265.80 |
- 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
- $2,511.89 / $3,388.44 / $6,606.93
| Professional | | $2,511.89 | $3,388.44 | $6,606.93 |