- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $3,388.44
| Professional | | $1,659.59 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,548.13
| Professional | | $3,467.37 | $3,467.37 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,897.79
| Professional | | $3,890.45 | $3,890.45 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $316.23 / $2,089.30
| Facility | | $213.80 | $316.23 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,884.03
| Professional | | $1,318.26 | $1,318.26 | $2,884.03 |