- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.74 / $1,040.98 / $1,490.27
| Professional | | $1,011.74 | $1,040.98 | $1,490.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,858.00 / $3,430.00 / $5,306.00
| Professional | | $2,858.00 | $3,430.00 | $5,306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.57 / $1,846.51 / $2,553.62
| Professional | | $1,103.57 | $1,846.51 | $2,553.62 |
- 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
- $1,222.96 / $2,133.96 / $3,855.79
| Professional | | $1,222.96 | $2,133.96 | $3,855.79 |