- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $3,467.37
| Professional | | $1,995.26 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,912.51 / $10,715.19
| Professional | | $5,754.40 | $8,912.51 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,630.78 / $7,413.10
| Professional | | $2,290.87 | $3,630.78 | $7,413.10 |
- 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 / $3,801.89 / $8,128.31
| Professional | | $2,511.89 | $3,801.89 | $8,128.31 |