- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,122.02 / $2,951.21
| Professional | | $1,096.48 | $1,122.02 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $3,467.37
| Professional | | $2,290.87 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $2,884.03
| Professional | | $1,621.81 | $1,995.26 | $2,884.03 |
- 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
- $1,445.44 / $2,290.87 / $4,466.84
| Professional | | $1,445.44 | $2,290.87 | $4,466.84 |