- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $2,041.74
| Professional | | $1,348.96 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,165.95 / $7,413.10
| Professional | | $3,981.07 | $6,165.95 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $4,677.35
| Professional | | $1,548.82 | $2,511.89 | $4,677.35 |
- 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 / $5,248.07
| Professional | | $1,584.89 | $2,570.40 | $5,248.07 |