- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.52 / $1,192.18 / $1,771.34
| Professional | | $1,153.52 | $1,192.18 | $1,771.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,401.00 / $4,081.00 / $6,316.00
| Professional | | $3,401.00 | $4,081.00 | $6,316.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.66 / $2,159.94 / $3,088.87
| Professional | | $1,335.66 | $2,159.94 | $3,088.87 |
- 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
- $1,355.75 / $2,663.54 / $5,037.10
| Professional | | $1,355.75 | $2,663.54 | $5,037.10 |