- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.92 / $1,804.92 / $1,804.92
| Professional | | $1,804.92 | $1,804.92 | $1,804.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,188.00 / $3,826.00 / $5,582.00
| Professional | | $3,188.00 | $3,826.00 | $5,582.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.21 / $2,958.49 / $3,429.15
| Professional | | $1,958.21 | $2,958.49 | $3,429.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $11,831.32 / $18,767.00
| Facility | | $5,188.00 | $11,831.32 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.79 / $3,864.88 / $5,961.13
| Professional | | $2,230.79 | $3,864.88 | $5,961.13 |