- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.13 / $1,086.71 / $1,596.15
| Professional | | $1,051.13 | $1,086.71 | $1,596.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,107.00 / $3,728.00 / $5,770.00
| Professional | | $3,107.00 | $3,728.00 | $5,770.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.05 / $1,974.97 / $2,776.09
| Professional | | $1,219.05 | $1,974.97 | $2,776.09 |
- 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
- $1,223.71 / $2,177.10 / $4,534.18
| Professional | | $1,223.71 | $2,177.10 | $4,534.18 |