- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.38 / $1,108.33 / $1,400.89
| Professional | | $1,092.38 | $1,108.33 | $1,400.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.00 / $2,510.00 / $3,797.00
| Professional | | $2,092.00 | $2,510.00 | $3,797.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.49 / $2,216.67 / $3,053.08
| Professional | | $1,505.49 | $2,216.67 | $3,053.08 |
- 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
- $1,504.30 / $2,160.50 / $4,006.59
| Professional | | $1,504.30 | $2,160.50 | $4,006.59 |