- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.21 / $1,248.89 / $1,861.41
| Professional | | $1,216.21 | $1,248.89 | $1,861.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,559.00 / $4,271.00 / $6,608.00
| Professional | | $3,559.00 | $4,271.00 | $6,608.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.87 / $2,262.80 / $3,073.53
| Professional | | $1,392.87 | $2,262.80 | $3,073.53 |
- 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
- $1,463.73 / $2,394.61 / $4,621.49
| Professional | | $1,463.73 | $2,394.61 | $4,621.49 |