- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.10 / $2,182.44 / $2,724.50
| Professional | | $2,137.10 | $2,182.44 | $2,724.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,131.00 / $4,957.00 / $7,500.00
| Professional | | $4,131.00 | $4,957.00 | $7,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,011.87 / $4,364.88 / $5,977.35
| Professional | | $3,011.87 | $4,364.88 | $5,977.35 |
- 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
- $2,771.14 / $4,332.41 / $7,550.40
| Professional | | $2,771.14 | $4,332.41 | $7,550.40 |