- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $3,715.35
| Professional | | $1,949.84 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,244.36 / $8,709.64
| Professional | | $4,466.84 | $7,244.36 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,168.69 / $5,495.41
| Professional | | $2,630.27 | $4,168.69 | $5,495.41 |
- 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
- $2,290.87 / $3,981.07 / $8,511.38
| Professional | | $2,290.87 | $3,981.07 | $8,511.38 |