- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.94 / $1,386.39 / $1,924.65
| Professional | | $1,298.94 | $1,386.39 | $1,924.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,713.00 / $4,456.00 / $6,894.00
| Professional | | $3,713.00 | $4,456.00 | $6,894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.17 / $2,357.57 / $3,437.27
| Professional | | $1,458.17 | $2,357.57 | $3,437.27 |
- 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
- $1,424.37 / $2,645.47 / $5,293.58
| Professional | | $1,424.37 | $2,645.47 | $5,293.58 |