- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.35 / $1,506.21 / $1,849.88
| Professional | | $1,425.35 | $1,506.21 | $1,849.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.00 / $3,536.00 / $5,694.00
| Professional | | $2,947.00 | $3,536.00 | $5,694.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.70 / $2,980.80 / $3,650.87
| Professional | | $1,849.70 | $2,980.80 | $3,650.87 |
- 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
- $1,660.99 / $3,038.26 / $5,164.89
| Professional | | $1,660.99 | $3,038.26 | $5,164.89 |