- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,288.25 / $2,344.23
| Professional | | $1,174.90 | $1,288.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,365.16 / $5,248.07
| Professional | | $2,691.53 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,311.31
| Professional | | $1,548.82 | $2,238.72 | $3,311.31 |
- 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 / $2,398.83 / $5,011.87
| Professional | | $1,318.26 | $2,398.83 | $5,011.87 |