- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $2,454.71
| Professional | | $1,258.93 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,981.07 / $4,786.30
| Professional | | $2,691.53 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $3,801.89
| Professional | | $1,659.59 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $25,703.96
| Facility | | $6,918.31 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $5,370.32
| Professional | | $1,513.56 | $2,511.89 | $5,370.32 |