- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.50 / $1,870.06 / $3,278.53
| Professional | | $1,312.50 | $1,870.06 | $3,278.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,609.00 / $7,931.00 / $12,270.00
| Professional | | $6,609.00 | $7,931.00 | $12,270.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.90 / $4,245.74 / $8,110.75
| Professional | | $1,853.90 | $4,245.74 | $8,110.75 |
- 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
- $2,716.28 / $4,251.34 / $13,981.59
| Professional | | $2,716.28 | $4,251.34 | $13,981.59 |