- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.40 / $1,035.28 / $1,533.61
| Professional | | $1,010.40 | $1,035.28 | $1,533.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.00 / $3,551.00 / $5,494.00
| Professional | | $2,959.00 | $3,551.00 | $5,494.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.66 / $1,879.45 / $2,670.39
| Professional | | $1,162.66 | $1,879.45 | $2,670.39 |
- 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
- $1,198.39 / $2,085.31 / $4,361.27
| Professional | | $1,198.39 | $2,085.31 | $4,361.27 |