- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.47 / $1,212.47 / $1,769.13
| Professional | | $1,190.47 | $1,212.47 | $1,769.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,408.00 / $4,090.00 / $6,326.00
| Professional | | $3,408.00 | $4,090.00 | $6,326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.29 / $2,166.94 / $3,248.47
| Professional | | $1,335.29 | $2,166.94 | $3,248.47 |
- 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
- $1,511.32 / $2,296.23 / $5,225.89
| Professional | | $1,511.32 | $2,296.23 | $5,225.89 |