- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.48 / $1,726.04 / $2,115.21
| Professional | | $1,677.48 | $1,726.04 | $2,115.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.00 / $4,246.00 / $6,835.00
| Professional | | $3,538.00 | $4,246.00 | $6,835.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.88 / $3,352.66 / $4,295.85
| Professional | | $2,097.88 | $3,352.66 | $4,295.85 |
- 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
- $2,439.71 / $3,468.02 / $5,861.70
| Professional | | $2,439.71 | $3,468.02 | $5,861.70 |