- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.11 / $1,605.97 / $2,077.16
| Professional | | $1,577.11 | $1,605.97 | $2,077.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,004.00 / $3,605.00 / $5,454.00
| Professional | | $3,004.00 | $3,605.00 | $5,454.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.44 / $3,195.66 / $4,389.72
| Professional | | $2,130.44 | $3,195.66 | $4,389.72 |
- 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
- $1,916.64 / $3,243.73 / $5,662.78
| Professional | | $1,916.64 | $3,243.73 | $5,662.78 |