- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.71 / $1,162.43 / $1,732.42
| Professional | | $1,097.71 | $1,162.43 | $1,732.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,310.00 / $3,972.00 / $6,146.00
| Professional | | $3,310.00 | $3,972.00 | $6,146.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.51 / $2,106.25 / $2,829.95
| Professional | | $1,297.51 | $2,106.25 | $2,829.95 |
- 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
- $1,304.89 / $2,327.86 / $4,637.16
| Professional | | $1,304.89 | $2,327.86 | $4,637.16 |