- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $3,019.95
| Professional | | $1,659.59 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,244.36 / $8,709.64
| Professional | | $4,677.35 | $7,244.36 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $5,888.44
| Professional | | $1,819.70 | $3,019.95 | $5,888.44 |
- 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
- $1,995.26 / $3,162.28 / $6,456.54
| Professional | | $1,995.26 | $3,162.28 | $6,456.54 |