- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.05 / $1,217.72 / $1,757.81
| Professional | | $1,192.05 | $1,217.72 | $1,757.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,354.00 / $4,025.00 / $6,227.00
| Professional | | $3,354.00 | $4,025.00 | $6,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.44 / $2,167.61 / $3,217.67
| Professional | | $1,298.44 | $2,167.61 | $3,217.67 |
- 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
- $1,381.68 / $2,318.17 / $5,250.98
| Professional | | $1,381.68 | $2,318.17 | $5,250.98 |