- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.88 / $1,200.93 / $1,790.63
| Professional | | $1,165.88 | $1,200.93 | $1,790.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,423.00 / $4,108.00 / $6,355.00
| Professional | | $3,423.00 | $4,108.00 | $6,355.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.86 / $2,176.38 / $3,077.12
| Professional | | $1,338.86 | $2,176.38 | $3,077.12 |
- 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
- $1,345.30 / $2,377.71 / $5,041.10
| Professional | | $1,345.30 | $2,377.71 | $5,041.10 |