- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $6,309.57
| Professional | | $2,290.87 | $2,511.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $9,772.37 / $9,772.37
| Professional | | $4,897.79 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,265.80 / $5,888.44
| Professional | | $3,235.94 | $4,265.80 | $5,888.44 |
- 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
- $2,884.03 / $4,897.79 / $8,511.38
| Professional | | $2,884.03 | $4,897.79 | $8,511.38 |