- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.49 / $2,622.62 / $2,775.14
| Professional | | $1,945.49 | $2,622.62 | $2,775.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.72 / $333.79 / $333.79
| Professional | | $283.72 | $333.79 | $333.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.91 / $2,671.66 / $2,671.66
| Professional | | $2,270.91 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.04 / $1,700.40 / $2,834.00
| Professional | | $1,351.04 | $1,700.40 | $2,834.00 |