- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $3,467.37
| Professional | | $1,905.46 | $3,019.95 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,715.35
| Professional | | $3,630.78 | $3,630.78 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $5,370.32
| Professional | | $1,698.24 | $1,698.24 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,630.27 / $3,311.31
| Professional | | $1,230.27 | $2,630.27 | $3,311.31 |