- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.27 / $1,216.17 / $1,813.37
| Professional | | $1,182.27 | $1,216.17 | $1,813.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.00 / $4,160.00 / $6,438.00
| Professional | | $3,467.00 | $4,160.00 | $6,438.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.37 / $2,204.94 / $3,120.49
| Professional | | $1,357.37 | $2,204.94 | $3,120.49 |
- 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
- $1,363.65 / $2,448.17 / $5,111.06
| Professional | | $1,363.65 | $2,448.17 | $5,111.06 |