- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $4,466.84
| Professional | | $1,584.89 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,128.61 / $6,165.95
| Professional | | $3,467.37 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $4,265.80
| Professional | | $2,290.87 | $3,019.95 | $4,265.80 |
- 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
- $1,949.84 / $3,548.13 / $6,025.60
| Professional | | $1,949.84 | $3,548.13 | $6,025.60 |