- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.38 / $1,349.19 / $2,001.13
| Professional | | $1,278.38 | $1,349.19 | $2,001.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.00 / $4,626.00 / $7,158.00
| Professional | | $3,855.00 | $4,626.00 | $7,158.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.92 / $2,448.17 / $3,287.17
| Professional | | $1,514.92 | $2,448.17 | $3,287.17 |
- 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
- $1,384.97 / $2,592.60 / $5,084.30
| Professional | | $1,384.97 | $2,592.60 | $5,084.30 |