- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.83 / $1,708.80 / $2,541.33
| Professional | | $1,669.83 | $1,708.80 | $2,541.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,868.00 / $5,842.00 / $9,037.00
| Professional | | $4,868.00 | $5,842.00 | $9,037.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.49 / $3,091.53 / $4,361.20
| Professional | | $1,909.49 | $3,091.53 | $4,361.20 |
- 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
- $1,921.53 / $3,523.64 / $7,164.96
| Professional | | $1,921.53 | $3,523.64 | $7,164.96 |