- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.21 / $1,438.48 / $1,767.34
| Professional | | $1,402.21 | $1,438.48 | $1,767.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.00 / $3,534.00 / $5,690.00
| Professional | | $2,945.00 | $3,534.00 | $5,690.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.15 / $2,804.40 / $3,587.50
| Professional | | $1,742.15 | $2,804.40 | $3,587.50 |
- 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
- $2,016.84 / $2,702.05 / $4,790.51
| Professional | | $2,016.84 | $2,702.05 | $4,790.51 |