- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.31 / $1,267.29 / $1,773.21
| Professional | | $1,199.31 | $1,267.29 | $1,773.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,422.00 / $4,106.00 / $6,354.00
| Professional | | $3,422.00 | $4,106.00 | $6,354.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.04 / $2,169.35 / $3,167.81
| Professional | | $1,436.04 | $2,169.35 | $3,167.81 |
- 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
- $1,459.63 / $2,441.25 / $5,353.41
| Professional | | $1,459.63 | $2,441.25 | $5,353.41 |