- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.93 / $2,037.66 / $2,615.07
| Professional | | $2,006.93 | $2,037.66 | $2,615.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,840.00 / $4,608.00 / $6,971.00
| Professional | | $3,840.00 | $4,608.00 | $6,971.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.52 / $3,765.78 / $5,573.62
| Professional | | $2,510.52 | $3,765.78 | $5,573.62 |
- 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
- $2,080.48 / $4,097.68 / $6,793.80
| Professional | | $2,080.48 | $4,097.68 | $6,793.80 |