- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.72 / $1,160.75 / $1,730.77
| Professional | | $1,144.72 | $1,160.75 | $1,730.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,307.00 / $3,968.00 / $6,139.00
| Professional | | $3,307.00 | $3,968.00 | $6,139.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.31 / $2,103.07 / $2,961.21
| Professional | | $1,294.31 | $2,103.07 | $2,961.21 |
- 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
- $1,315.74 / $2,349.48 / $4,903.81
| Professional | | $1,315.74 | $2,349.48 | $4,903.81 |