- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $3,388.44
| Professional | | $1,348.96 | $1,513.56 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,630.78 / $4,265.80
| Professional | | $3,162.28 | $3,630.78 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $3,311.31
| Professional | | $1,949.84 | $2,041.74 | $3,311.31 |
- 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
- $1,737.80 / $2,691.53 / $5,370.32
| Professional | | $1,737.80 | $2,691.53 | $5,370.32 |