- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.28 / $1,077.94 / $1,605.51
| Professional | | $1,050.28 | $1,077.94 | $1,605.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.00 / $3,694.00 / $5,714.00
| Professional | | $3,078.00 | $3,694.00 | $5,714.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.35 / $1,956.87 / $2,732.40
| Professional | | $1,205.35 | $1,956.87 | $2,732.40 |
- 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
- $1,211.15 / $2,165.94 / $4,531.56
| Professional | | $1,211.15 | $2,165.94 | $4,531.56 |