- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.72 / $1,505.56 / $2,234.19
| Professional | | $1,455.72 | $1,505.56 | $2,234.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,303.00 / $5,164.00 / $7,988.00
| Professional | | $4,303.00 | $5,164.00 | $7,988.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.87 / $2,733.60 / $3,813.92
| Professional | | $1,687.87 | $2,733.60 | $3,813.92 |
- 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
- $1,693.09 / $3,003.58 / $6,270.02
| Professional | | $1,693.09 | $3,003.58 | $6,270.02 |