- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.53 / $1,595.18 / $1,956.62
| Professional | | $1,552.53 | $1,595.18 | $1,956.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,269.00 / $3,923.00 / $6,314.00
| Professional | | $3,269.00 | $3,923.00 | $6,314.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.84 / $3,096.00 / $3,972.96
| Professional | | $1,929.84 | $3,096.00 | $3,972.96 |
- 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
- $1,787.52 / $3,200.56 / $5,336.48
| Professional | | $1,787.52 | $3,200.56 | $5,336.48 |