- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.93 / $1,516.44 / $2,265.63
| Professional | | $1,462.93 | $1,516.44 | $2,265.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,311.00 / $5,173.00 / $8,004.00
| Professional | | $4,311.00 | $5,173.00 | $8,004.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.14 / $2,742.94 / $3,861.89
| Professional | | $1,687.14 | $2,742.94 | $3,861.89 |
- 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
- $1,696.83 / $2,898.01 / $6,324.11
| Professional | | $1,696.83 | $2,898.01 | $6,324.11 |