- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.40 / $1,993.64 / $2,810.87
| Professional | | $1,260.40 | $1,993.64 | $2,810.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.51 / $1,621.78 / $3,473.68
| Professional | | $1,310.51 | $1,621.78 | $3,473.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.49 / $2,777.18 / $3,227.41
| Professional | | $1,672.49 | $2,777.18 | $3,227.41 |
- 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
- $1,469.69 / $2,369.83 / $3,657.90
| Professional | | $1,469.69 | $2,369.83 | $3,657.90 |