- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.81 / $1,591.01 / $2,360.32
| Professional | | $1,542.81 | $1,591.01 | $2,360.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,546.00 / $5,455.00 / $8,440.00
| Professional | | $4,546.00 | $5,455.00 | $8,440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.15 / $2,887.34 / $3,904.28
| Professional | | $1,782.15 | $2,887.34 | $3,904.28 |
- 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
- $1,787.36 / $3,153.33 / $6,680.51
| Professional | | $1,787.36 | $3,153.33 | $6,680.51 |