- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.49 / $1,711.36 / $2,098.04
| Professional | | $1,664.49 | $1,711.36 | $2,098.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,508.00 / $4,210.00 / $6,776.00
| Professional | | $3,508.00 | $4,210.00 | $6,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.19 / $3,316.67 / $4,259.78
| Professional | | $2,075.19 | $3,316.67 | $4,259.78 |
- 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
- $1,921.29 / $3,438.76 / $5,796.68
| Professional | | $1,921.29 | $3,438.76 | $5,796.68 |