- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.31 / $1,123.63 / $1,415.06
| Professional | | $1,115.31 | $1,123.63 | $1,415.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.00 / $2,572.00 / $3,892.00
| Professional | | $2,143.00 | $2,572.00 | $3,892.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.06 / $2,247.25 / $3,093.43
| Professional | | $1,525.06 | $2,247.25 | $3,093.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.61 / $2,235.87 / $3,786.90
| Professional | | $1,276.61 | $2,235.87 | $3,786.90 |