- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.16 / $1,652.42 / $2,449.88
| Professional | | $1,609.16 | $1,652.42 | $2,449.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,720.00 / $5,664.00 / $8,764.00
| Professional | | $4,720.00 | $5,664.00 | $8,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.77 / $2,996.14 / $4,254.78
| Professional | | $1,854.77 | $2,996.14 | $4,254.78 |
- 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
- $1,861.04 / $3,405.34 / $6,981.48
| Professional | | $1,861.04 | $3,405.34 | $6,981.48 |