- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.88 / $2,176.73 / $2,662.96
| Professional | | $2,111.88 | $2,176.73 | $2,662.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,458.00 / $5,350.00 / $8,612.00
| Professional | | $4,458.00 | $5,350.00 | $8,612.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.88 / $4,237.52 / $5,407.21
| Professional | | $2,630.88 | $4,237.52 | $5,407.21 |
- 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
- $2,427.44 / $4,383.96 / $7,269.58
| Professional | | $2,427.44 | $4,383.96 | $7,269.58 |