- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.69 / $1,829.45 / $2,290.46
| Professional | | $1,790.69 | $1,829.45 | $2,290.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,461.00 / $4,153.00 / $6,282.00
| Professional | | $3,461.00 | $4,153.00 | $6,282.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.16 / $3,658.91 / $5,011.27
| Professional | | $2,525.16 | $3,658.91 | $5,011.27 |
- 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
- $2,551.92 / $3,665.12 / $6,862.69
| Professional | | $2,551.92 | $3,665.12 | $6,862.69 |