- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $9,772.37
| Professional | | $3,467.37 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $13,182.57 / $15,848.93
| Professional | | $8,128.31 | $13,182.57 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $9,549.93
| Professional | | $5,128.61 | $6,606.93 | $9,549.93 |
- 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
- $4,265.80 / $7,943.28 / $13,803.84
| Professional | | $4,265.80 | $7,943.28 | $13,803.84 |