- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $2,238.72
| Professional | | $1,412.54 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,456.54 / $7,762.47
| Professional | | $4,168.69 | $6,456.54 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,630.27 / $5,011.87
| Professional | | $1,621.81 | $2,630.27 | $5,011.87 |
- 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
- $1,621.81 / $2,691.53 / $5,370.32
| Professional | | $1,621.81 | $2,691.53 | $5,370.32 |