- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $4,677.35
| Professional | | $2,344.23 | $2,630.27 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,511.38 / $10,232.93
| Professional | | $5,370.32 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,011.87 / $6,456.54
| Professional | | $3,162.28 | $5,011.87 | $6,456.54 |
- 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
- $2,951.21 / $4,677.35 / $10,232.93
| Professional | | $2,951.21 | $4,677.35 | $10,232.93 |