- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.28 / $1,199.71 / $1,505.78
| Professional | | $1,182.28 | $1,199.71 | $1,505.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.00 / $2,736.00 / $4,139.00
| Professional | | $2,280.00 | $2,736.00 | $4,139.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.05 / $2,399.41 / $3,280.45
| Professional | | $1,643.05 | $2,399.41 | $3,280.45 |
- 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
- $1,415.48 / $2,405.11 / $4,182.09
| Professional | | $1,415.48 | $2,405.11 | $4,182.09 |