- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.77 / $1,866.24 / $2,728.71
| Professional | | $1,169.77 | $1,866.24 | $2,728.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.63 / $1,607.94 / $3,228.06
| Professional | | $1,222.63 | $1,607.94 | $3,228.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.63 / $2,510.81 / $3,177.15
| Professional | | $1,564.63 | $2,510.81 | $3,177.15 |
- 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
- $1,402.01 / $2,303.67 / $3,558.37
| Professional | | $1,402.01 | $2,303.67 | $3,558.37 |