- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.58 / $1,173.35 / $1,751.23
| Professional | | $1,134.58 | $1,173.35 | $1,751.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,372.00 / $4,046.00 / $6,260.00
| Professional | | $3,372.00 | $4,046.00 | $6,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.75 / $2,150.19 / $2,981.27
| Professional | | $1,318.75 | $2,150.19 | $2,981.27 |
- 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
- $1,187.20 / $2,227.81 / $4,897.18
| Professional | | $1,187.20 | $2,227.81 | $4,897.18 |