- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $3,801.89
| Professional | | $1,348.96 | $1,479.11 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,128.61 / $5,128.61
| Professional | | $3,467.37 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $3,548.13
| Professional | | $1,862.09 | $2,570.40 | $3,548.13 |
- 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 / $3,019.95 / $5,011.87
| Professional | | $1,621.81 | $3,019.95 | $5,011.87 |