- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.17 / $1,257.00 / $1,866.49
| Professional | | $1,235.17 | $1,257.00 | $1,866.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,594.00 / $4,313.00 / $6,673.00
| Professional | | $3,594.00 | $4,313.00 | $6,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.32 / $2,282.87 / $3,225.30
| Professional | | $1,410.32 | $2,282.87 | $3,225.30 |
- 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
- $1,442.63 / $2,549.76 / $5,319.62
| Professional | | $1,442.63 | $2,549.76 | $5,319.62 |