- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,819.70
| Professional | | $1,174.90 | $1,318.26 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $6,456.54
| Professional | | $3,467.37 | $5,370.32 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,168.69
| Professional | | $1,380.38 | $2,187.76 | $4,168.69 |
- 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
- $1,380.38 / $2,238.72 / $4,570.88
| Professional | | $1,380.38 | $2,238.72 | $4,570.88 |