- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,397.02 / $3,231.31 / $3,419.19
| Professional | | $2,397.02 | $3,231.31 | $3,419.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.57 / $411.26 / $411.26
| Professional | | $349.57 | $411.26 | $411.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.87 / $3,657.49 / $3,657.49
| Professional | | $3,108.87 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.60 / $2,427.36 / $3,519.93
| Professional | | $1,664.60 | $2,427.36 | $3,519.93 |