- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.82 / $1,195.54 / $1,774.38
| Professional | | $1,163.82 | $1,195.54 | $1,774.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.00 / $4,102.00 / $6,346.00
| Professional | | $3,418.00 | $4,102.00 | $6,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.53 / $2,171.42 / $3,044.02
| Professional | | $1,341.53 | $2,171.42 | $3,044.02 |
- 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
- $1,345.65 / $2,370.27 / $5,018.64
| Professional | | $1,345.65 | $2,370.27 | $5,018.64 |