- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.51 / $1,238.28 / $1,845.99
| Professional | | $1,204.51 | $1,238.28 | $1,845.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,530.00 / $4,236.00 / $6,553.00
| Professional | | $3,530.00 | $4,236.00 | $6,553.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.99 / $2,244.38 / $3,180.40
| Professional | | $1,381.99 | $2,244.38 | $3,180.40 |
- 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
- $1,379.41 / $2,491.65 / $5,206.07
| Professional | | $1,379.41 | $2,491.65 | $5,206.07 |