- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.13 / $1,142.21 / $1,699.74
| Professional | | $1,109.13 | $1,142.21 | $1,699.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,260.00 / $3,912.00 / $6,053.00
| Professional | | $3,260.00 | $3,912.00 | $6,053.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.90 / $2,072.75 / $2,927.66
| Professional | | $1,276.90 | $2,072.75 | $2,927.66 |
- 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
- $1,282.47 / $2,310.83 / $4,214.60
| Professional | | $1,282.47 | $2,310.83 | $4,214.60 |