- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.98 / $1,348.27 / $2,008.14
| Professional | | $1,312.98 | $1,348.27 | $2,008.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,842.00 / $4,610.00 / $7,134.00
| Professional | | $3,842.00 | $4,610.00 | $7,134.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.07 / $2,442.13 / $3,416.23
| Professional | | $1,505.07 | $2,442.13 | $3,416.23 |
- 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
- $1,514.49 / $2,731.67 / $5,676.01
| Professional | | $1,514.49 | $2,731.67 | $5,676.01 |