- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.80 / $1,551.35 / $2,381.31
| Professional | | $1,010.80 | $1,551.35 | $2,381.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.01 / $1,410.41 / $2,789.70
| Professional | | $1,058.01 | $1,410.41 | $2,789.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.03 / $2,261.54 / $2,788.85
| Professional | | $1,355.03 | $2,261.54 | $2,788.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.00 / $5,979.00 / $12,680.00
| Facility | | $2,609.00 | $5,979.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.48 / $1,999.50 / $3,109.84
| Professional | | $1,228.48 | $1,999.50 | $3,109.84 |