- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.56 / $1,725.97 / $2,188.42
| Professional | | $1,699.56 | $1,725.97 | $2,188.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,239.00 / $3,887.00 / $5,879.00
| Professional | | $3,239.00 | $3,887.00 | $5,879.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.28 / $3,451.94 / $4,722.10
| Professional | | $2,405.28 | $3,451.94 | $4,722.10 |
- 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
- $2,421.58 / $3,477.92 / $5,739.50
| Professional | | $2,421.58 | $3,477.92 | $5,739.50 |