- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $3,235.94
| Professional | | $1,258.93 | $1,445.44 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $4,168.69
| Professional | | $2,398.83 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,162.28
| Professional | | $1,862.09 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,570.40 / $4,897.79
| Professional | | $1,584.89 | $2,570.40 | $4,897.79 |