- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,254.04 / $1,863.67
| Professional | | $1,227.04 | $1,254.04 | $1,863.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,578.00 / $4,294.00 / $6,642.00
| Professional | | $3,578.00 | $4,294.00 | $6,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.37 / $2,271.69 / $3,226.47
| Professional | | $1,403.37 | $2,271.69 | $3,226.47 |
- 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
- $1,424.43 / $2,547.87 / $5,274.71
| Professional | | $1,424.43 | $2,547.87 | $5,274.71 |