- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.48 / $1,585.44 / $2,359.50
| Professional | | $1,576.48 | $1,585.44 | $2,359.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,516.00 / $5,419.00 / $8,383.00
| Professional | | $4,516.00 | $5,419.00 | $8,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.22 / $2,868.64 / $4,019.31
| Professional | | $1,768.22 | $2,868.64 | $4,019.31 |
- 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
- $1,816.47 / $3,195.36 / $6,730.69
| Professional | | $1,816.47 | $3,195.36 | $6,730.69 |