- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.85 / $2,681.19 / $3,780.86
| Professional | | $1,708.85 | $2,681.19 | $3,780.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.70 / $2,185.32 / $4,711.04
| Professional | | $1,776.70 | $2,185.32 | $4,711.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,267.67 / $3,728.76 / $4,361.17
| Professional | | $2,267.67 | $3,728.76 | $4,361.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,919.57 / $3,161.50 / $4,914.38
| Professional | | $1,919.57 | $3,161.50 | $4,914.38 |