- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.05 / $1,254.61 / $1,789.74
| Professional | | $1,207.05 | $1,254.61 | $1,789.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,451.00 / $4,141.00 / $6,407.00
| Professional | | $3,451.00 | $4,141.00 | $6,407.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.17 / $2,191.98 / $3,155.73
| Professional | | $1,355.17 | $2,191.98 | $3,155.73 |
- 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
- $1,498.12 / $2,456.60 / $5,340.71
| Professional | | $1,498.12 | $2,456.60 | $5,340.71 |