- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.78 / $1,223.14 / $1,699.31
| Professional | | $1,073.78 | $1,223.14 | $1,699.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,233.00 / $3,880.00 / $6,002.00
| Professional | | $3,233.00 | $3,880.00 | $6,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.98 / $1,942.64 / $2,703.72
| Professional | | $1,260.98 | $1,942.64 | $2,703.72 |
- 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
- $1,240.41 / $2,197.29 / $4,408.82
| Professional | | $1,240.41 | $2,197.29 | $4,408.82 |