- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,047.13 / $2,630.27
| Professional | | $933.25 | $1,047.13 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,951.21 / $3,548.13
| Professional | | $1,995.26 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $2,398.83
| Professional | | $1,412.54 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $14,125.38
| Facility | | $4,168.69 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,089.30 / $3,715.35
| Professional | | $1,230.27 | $2,089.30 | $3,715.35 |