- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,095.23 / $1,496.67
| Professional | | $1,011.49 | $1,095.23 | $1,496.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,883.00 / $3,460.00 / $5,353.00
| Professional | | $2,883.00 | $3,460.00 | $5,353.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.00 / $1,829.19 / $2,659.89
| Professional | | $1,210.00 | $1,829.19 | $2,659.89 |
- 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
- $1,294.17 / $2,270.67 / $4,670.16
| Professional | | $1,294.17 | $2,270.67 | $4,670.16 |