- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.64 / $1,167.52 / $1,738.39
| Professional | | $1,137.64 | $1,167.52 | $1,738.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,334.00 / $4,001.00 / $6,190.00
| Professional | | $3,334.00 | $4,001.00 | $6,190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.17 / $2,119.77 / $2,993.47
| Professional | | $1,306.17 | $2,119.77 | $2,993.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.01 / $2,311.36 / $4,895.85
| Professional | | $1,323.01 | $2,311.36 | $4,895.85 |