- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.72 / $2,028.58 / $2,863.05
| Professional | | $1,303.72 | $2,028.58 | $2,863.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.95 / $1,715.78 / $3,616.26
| Professional | | $1,347.95 | $1,715.78 | $3,616.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.32 / $2,896.12 / $3,414.49
| Professional | | $1,723.32 | $2,896.12 | $3,414.49 |
- 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
- $1,539.60 / $2,480.07 / $3,829.43
| Professional | | $1,539.60 | $2,480.07 | $3,829.43 |