- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.81 / $1,597.08 / $1,958.64
| Professional | | $1,553.81 | $1,597.08 | $1,958.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,271.00 / $3,925.00 / $6,319.00
| Professional | | $3,271.00 | $3,925.00 | $6,319.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.44 / $3,098.88 / $3,976.56
| Professional | | $1,932.44 | $3,098.88 | $3,976.56 |
- 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
- $1,782.97 / $3,197.76 / $5,332.61
| Professional | | $1,782.97 | $3,197.76 | $5,332.61 |