- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.68 / $1,535.54 / $1,933.02
| Professional | | $1,512.68 | $1,535.54 | $1,933.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,905.00 / $3,486.00 / $5,273.00
| Professional | | $2,905.00 | $3,486.00 | $5,273.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.64 / $2,651.46 / $4,197.35
| Professional | | $1,767.64 | $2,651.46 | $4,197.35 |
- 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
- $1,673.58 / $3,078.66 / $5,081.68
| Professional | | $1,673.58 | $3,078.66 | $5,081.68 |