- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,348.96 / $3,467.37
| Professional | | $1,258.93 | $1,348.96 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,011.87 / $5,888.44
| Professional | | $2,884.03 | $5,011.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $3,235.94
| Professional | | $1,819.70 | $2,344.23 | $3,235.94 |
- 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
- $1,548.82 / $2,754.23 / $4,786.30
| Professional | | $1,548.82 | $2,754.23 | $4,786.30 |