- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.29 / $1,643.14 / $2,436.14
| Professional | | $1,638.29 | $1,643.14 | $2,436.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,601.00 / $5,521.00 / $8,542.00
| Professional | | $4,601.00 | $5,521.00 | $8,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.20 / $2,973.02 / $4,499.97
| Professional | | $1,778.20 | $2,973.02 | $4,499.97 |
- 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
- $1,911.53 / $3,284.34 / $7,013.17
| Professional | | $1,911.53 | $3,284.34 | $7,013.17 |