- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.93 / $2,075.71 / $2,538.21
| Professional | | $2,011.93 | $2,075.71 | $2,538.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,249.00 / $5,099.00 / $8,208.00
| Professional | | $4,249.00 | $5,099.00 | $8,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.26 / $4,039.36 / $5,151.71
| Professional | | $2,527.26 | $4,039.36 | $5,151.71 |
- 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
- $2,200.32 / $4,179.88 / $7,049.90
| Professional | | $2,200.32 | $4,179.88 | $7,049.90 |