- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.82 / $1,099.09 / $1,632.34
| Professional | | $1,065.82 | $1,099.09 | $1,632.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,772.00 / $5,836.00
| Professional | | $3,143.00 | $3,772.00 | $5,836.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.61 / $1,997.55 / $2,809.28
| Professional | | $1,232.61 | $1,997.55 | $2,809.28 |
- 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
- $1,118.72 / $2,176.83 / $4,614.70
| Professional | | $1,118.72 | $2,176.83 | $4,614.70 |