- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.05 / $1,272.63 / $1,889.05
| Professional | | $1,259.05 | $1,272.63 | $1,889.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.00 / $4,366.00 / $6,755.00
| Professional | | $3,638.00 | $4,366.00 | $6,755.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.05 / $2,310.87 / $3,266.32
| Professional | | $1,428.05 | $2,310.87 | $3,266.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.09 / $2,567.25 / $5,376.35
| Professional | | $1,458.09 | $2,567.25 | $5,376.35 |