- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.67 / $1,419.79 / $1,789.92
| Professional | | $1,408.67 | $1,419.79 | $1,789.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,696.00 / $3,235.00 / $4,894.00
| Professional | | $2,696.00 | $3,235.00 | $4,894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.36 / $2,579.03 / $3,902.27
| Professional | | $1,719.36 | $2,579.03 | $3,902.27 |
- 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
- $1,493.10 / $2,839.74 / $4,529.18
| Professional | | $1,493.10 | $2,839.74 | $4,529.18 |