- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.64 / $1,431.27 / $1,962.81
| Professional | | $1,251.64 | $1,431.27 | $1,962.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.79 / $253.79 / $290.08
| Professional | | $253.79 | $253.79 | $290.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,152.68 / $4,152.68 / $4,152.68
| Facility | | $4,152.68 | $4,152.68 | $4,152.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.64 / $2,381.86 / $2,836.27
| Professional | | $1,885.64 | $2,381.86 | $2,836.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.22 / $1,503.98 / $2,690.81
| Professional | | $1,153.22 | $1,503.98 | $2,690.81 |