- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.64 / $1,358.43 / $1,869.45
| Professional | | $1,261.64 | $1,358.43 | $1,869.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,608.00 / $4,330.00 / $6,698.00
| Professional | | $3,608.00 | $4,330.00 | $6,698.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.09 / $2,290.98 / $3,312.87
| Professional | | $1,416.09 | $2,290.98 | $3,312.87 |
- 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
- $1,608.98 / $2,823.03 / $5,600.78
| Professional | | $1,608.98 | $2,823.03 | $5,600.78 |