- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.71 / $2,202.84 / $2,695.48
| Professional | | $2,054.71 | $2,202.84 | $2,695.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,512.00 / $5,414.00 / $8,717.00
| Professional | | $4,512.00 | $5,414.00 | $8,717.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.31 / $4,193.06 / $5,471.65
| Professional | | $2,662.31 | $4,193.06 | $5,471.65 |
- 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
- $2,465.83 / $4,152.84 / $7,344.99
| Professional | | $2,465.83 | $4,152.84 | $7,344.99 |