- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.63 / $1,382.35 / $1,971.88
| Professional | | $1,333.63 | $1,382.35 | $1,971.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,808.00 / $4,570.00 / $7,070.00
| Professional | | $3,808.00 | $4,570.00 | $7,070.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.30 / $2,415.92 / $3,479.62
| Professional | | $1,497.30 | $2,415.92 | $3,479.62 |
- 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
- $1,687.31 / $2,720.27 / $5,912.26
| Professional | | $1,687.31 | $2,720.27 | $5,912.26 |