- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.91 / $1,162.21 / $1,727.94
| Professional | | $1,129.91 | $1,162.21 | $1,727.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,315.00 / $3,978.00 / $6,154.00
| Professional | | $3,315.00 | $3,978.00 | $6,154.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.61 / $2,105.53 / $2,984.14
| Professional | | $1,299.61 | $2,105.53 | $2,984.14 |
- 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
- $1,313.01 / $2,360.27 / $4,878.72
| Professional | | $1,313.01 | $2,360.27 | $4,878.72 |