- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.31 / $2,186.53 / $2,337.32
| Professional | | $1,671.31 | $2,186.53 | $2,337.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.25 / $2,513.25 / $3,769.88
| Professional | | $2,513.25 | $2,513.25 | $3,769.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.87 / $4,950.00 / $4,950.00
| Facility | | $2,060.87 | $4,950.00 | $4,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,256.63 / $2,079.00
| Professional | | $1,055.57 | $1,256.63 | $2,079.00 |