- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.55 / $1,065.83 / $1,592.34
| Professional | | $1,034.55 | $1,065.83 | $1,592.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,036.00 / $3,643.00 / $5,636.00
| Professional | | $3,036.00 | $3,643.00 | $5,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.55 / $1,932.50 / $2,734.79
| Professional | | $1,188.55 | $1,932.50 | $2,734.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.53 / $2,153.01 / $4,465.55
| Professional | | $1,195.53 | $2,153.01 | $4,465.55 |