- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.40 / $1,604.82 / $2,208.81
| Professional | | $1,450.40 | $1,604.82 | $2,208.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,248.00 / $5,098.00 / $7,888.00
| Professional | | $4,248.00 | $5,098.00 | $7,888.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.97 / $2,697.11 / $3,823.45
| Professional | | $1,666.97 | $2,697.11 | $3,823.45 |
- 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
- $1,677.30 / $3,004.47 / $6,277.93
| Professional | | $1,677.30 | $3,004.47 | $6,277.93 |