- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.17 / $1,245.66 / $1,844.42
| Professional | | $1,217.17 | $1,245.66 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,592.00 / $4,310.00 / $6,670.00
| Professional | | $3,592.00 | $4,310.00 | $6,670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.87 / $2,284.11 / $3,230.39
| Professional | | $1,406.87 | $2,284.11 | $3,230.39 |
- 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
- $1,417.16 / $2,521.23 / $5,240.39
| Professional | | $1,417.16 | $2,521.23 | $5,240.39 |