- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.53 / $1,228.17 / $1,827.25
| Professional | | $1,192.53 | $1,228.17 | $1,827.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,508.00 / $4,210.00 / $6,514.00
| Professional | | $3,508.00 | $4,210.00 | $6,514.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.87 / $2,229.32 / $3,166.88
| Professional | | $1,375.87 | $2,229.32 | $3,166.88 |
- 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
- $1,380.63 / $2,489.56 / $5,166.47
| Professional | | $1,380.63 | $2,489.56 | $5,166.47 |