- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,548.13 / $4,786.30
| Professional | | $3,090.30 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $14,125.38 / $16,982.44
| Professional | | $9,120.11 | $14,125.38 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,888.44 / $10,964.78
| Professional | | $3,630.78 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,025.60 / $11,481.54
| Professional | | $3,630.78 | $6,025.60 | $11,481.54 |