- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.75 / $1,238.05 / $1,838.01
| Professional | | $1,199.75 | $1,238.05 | $1,838.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,537.00 / $4,244.00 / $6,566.00
| Professional | | $3,537.00 | $4,244.00 | $6,566.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.41 / $2,246.87 / $3,148.18
| Professional | | $1,388.41 | $2,246.87 | $3,148.18 |
- 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
- $1,408.98 / $2,511.11 / $5,229.84
| Professional | | $1,408.98 | $2,511.11 | $5,229.84 |