- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $3,311.31
| Professional | | $1,071.52 | $1,445.44 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $3,019.95
| Professional | | $2,137.96 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $3,019.95
| Professional | | $1,584.89 | $2,290.87 | $3,019.95 |
- 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
- $1,412.54 / $2,398.83 / $3,801.89
| Professional | | $1,412.54 | $2,398.83 | $3,801.89 |