- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.91 / $1,570.87 / $1,991.92
| Professional | | $1,547.91 | $1,570.87 | $1,991.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,948.00 / $3,538.00 / $5,352.00
| Professional | | $2,948.00 | $3,538.00 | $5,352.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.21 / $3,141.74 / $4,299.74
| Professional | | $2,189.21 | $3,141.74 | $4,299.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.90 / $3,129.51 / $5,181.78
| Professional | | $1,757.90 | $3,129.51 | $5,181.78 |