- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.56 / $1,812.82 / $2,505.78
| Professional | | $1,689.56 | $1,812.82 | $2,505.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,671.00 / $5,605.00 / $8,672.00
| Professional | | $4,671.00 | $5,605.00 | $8,672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.54 / $3,014.76 / $4,419.59
| Professional | | $1,814.54 | $3,014.76 | $4,419.59 |
- 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
- $1,981.56 / $3,419.34 / $7,282.42
| Professional | | $1,981.56 | $3,419.34 | $7,282.42 |