- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.84 / $1,386.81 / $1,929.23
| Professional | | $1,303.84 | $1,386.81 | $1,929.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,717.00 / $4,460.00 / $6,901.00
| Professional | | $3,717.00 | $4,460.00 | $6,901.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.78 / $2,357.59 / $3,556.90
| Professional | | $1,559.78 | $2,357.59 | $3,556.90 |
- 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
- $1,668.54 / $2,659.38 / $5,872.67
| Professional | | $1,668.54 | $2,659.38 | $5,872.67 |