- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.75 / $1,230.38 / $1,557.86
| Professional | | $1,214.75 | $1,230.38 | $1,557.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.00 / $3,010.00 / $4,844.00
| Professional | | $2,508.00 | $3,010.00 | $4,844.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.89 / $2,502.13 / $3,110.71
| Professional | | $1,554.89 | $2,502.13 | $3,110.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.05 / $2,509.60 / $4,351.10
| Professional | | $1,404.05 | $2,509.60 | $4,351.10 |