- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.85 / $7,001.33 / $7,001.33
| Professional | | $2,218.85 | $7,001.33 | $7,001.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.33 / $2,934.79 / $3,452.70
| Professional | | $2,645.33 | $2,934.79 | $3,452.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.66 / $3,229.61 / $4,301.84
| Professional | | $2,020.66 | $3,229.61 | $4,301.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,326.68 / $1,776.18 / $2,372.11
| Facility | | $1,326.68 | $1,776.18 | $2,372.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.28 / $2,486.14 / $3,427.34
| Professional | | $1,400.28 | $2,486.14 | $3,427.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.28 / $2,433.79 / $3,080.62
| Professional | | $1,400.28 | $2,433.79 | $3,080.62 |