- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,698.24 / $4,466.84
| Professional | | $1,659.59 | $1,698.24 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,365.16 / $5,248.07
| Professional | | $3,467.37 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $4,265.80
| Professional | | $2,454.71 | $3,019.95 | $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 / $3,467.37 / $6,606.93
| Professional | | $2,187.76 | $3,467.37 | $6,606.93 |