- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.07 / $1,722.06 / $2,567.55
| Professional | | $1,670.07 | $1,722.06 | $2,567.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,900.00 / $5,880.00 / $9,097.00
| Professional | | $4,900.00 | $5,880.00 | $9,097.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.19 / $3,115.41 / $4,410.54
| Professional | | $1,917.19 | $3,115.41 | $4,410.54 |
- 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
- $2,001.39 / $3,828.83 / $6,328.38
| Professional | | $2,001.39 | $3,828.83 | $6,328.38 |