- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $3,981.07
| Professional | | $1,659.59 | $1,862.09 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,265.80 / $5,128.61
| Professional | | $3,801.89 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $4,265.80
| Professional | | $2,511.89 | $2,511.89 | $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
- $2,187.76 / $3,235.94 / $6,606.93
| Professional | | $2,187.76 | $3,235.94 | $6,606.93 |