- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,047.13 / $2,754.23
| Professional | | $1,023.29 | $1,047.13 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $3,235.94
| Professional | | $2,137.96 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,630.27
| Professional | | $1,513.56 | $1,819.70 | $2,630.27 |
- 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
- $1,318.26 / $2,137.96 / $4,073.80
| Professional | | $1,318.26 | $2,137.96 | $4,073.80 |