- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.72 / $1,379.78 / $1,950.79
| Professional | | $1,314.72 | $1,379.78 | $1,950.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,761.00 / $4,513.00 / $6,982.00
| Professional | | $3,761.00 | $4,513.00 | $6,982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.98 / $2,389.96 / $3,603.57
| Professional | | $1,474.98 | $2,389.96 | $3,603.57 |
- 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
- $1,573.15 / $2,652.93 / $5,225.99
| Professional | | $1,573.15 | $2,652.93 | $5,225.99 |