- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $1,659.59
| Professional | | $1,230.27 | $1,479.11 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $5,623.41
| Professional | | $2,187.76 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $1,737.80
| Professional | | $741.31 | $741.31 | $1,737.80 |