- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.72 / $1,554.11 / $1,953.58
| Professional | | $1,540.72 | $1,554.11 | $1,953.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,963.00 / $3,556.00 / $5,380.00
| Professional | | $2,963.00 | $3,556.00 | $5,380.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.42 / $3,108.22 / $4,269.22
| Professional | | $2,125.42 | $3,108.22 | $4,269.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,192.26 / $2,773.89 / $5,319.60
| Professional | | $2,192.26 | $2,773.89 | $5,319.60 |