- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $5,754.40
| Professional | | $2,089.30 | $2,137.96 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $9,332.54
| Professional | | $4,786.30 | $7,762.47 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $5,623.41
| Professional | | $3,019.95 | $3,890.45 | $5,623.41 |
- 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
- $2,630.27 / $4,677.35 / $7,943.28
| Professional | | $2,630.27 | $4,677.35 | $7,943.28 |