- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.49 / $1,413.59 / $1,734.64
| Professional | | $1,377.49 | $1,413.59 | $1,734.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,899.00 / $3,479.00 / $5,600.00
| Professional | | $2,899.00 | $3,479.00 | $5,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.08 / $2,752.17 / $3,521.80
| Professional | | $1,710.08 | $2,752.17 | $3,521.80 |
- 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
- $1,547.10 / $2,786.80 / $4,761.88
| Professional | | $1,547.10 | $2,786.80 | $4,761.88 |