- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.44 / $1,555.81 / $2,305.32
| Professional | | $1,519.44 | $1,555.81 | $2,305.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,446.00 / $5,335.00 / $8,255.00
| Professional | | $4,446.00 | $5,335.00 | $8,255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.66 / $2,821.64 / $3,990.36
| Professional | | $1,745.66 | $2,821.64 | $3,990.36 |
- 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
- $1,778.27 / $3,163.92 / $6,577.55
| Professional | | $1,778.27 | $3,163.92 | $6,577.55 |