- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.56 / $1,764.27 / $2,534.44
| Professional | | $1,716.56 | $1,764.27 | $2,534.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,802.00 / $5,762.00 / $8,915.00
| Professional | | $4,802.00 | $5,762.00 | $8,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.53 / $3,101.22 / $4,547.41
| Professional | | $1,860.53 | $3,101.22 | $4,547.41 |
- 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
- $2,033.86 / $3,362.84 / $7,653.36
| Professional | | $2,033.86 | $3,362.84 | $7,653.36 |