- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.66 / $5,400.00 / $5,621.40
| Professional | | $1,951.66 | $5,400.00 | $5,621.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.00 / $2,949.00 / $3,539.00
| Professional | | $1,824.00 | $2,949.00 | $3,539.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.59 / $1,303.54 / $1,882.89
| Professional | | $965.59 | $1,303.54 | $1,882.89 |
- 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
- $1,369.47 / $1,864.61 / $3,758.31
| Professional | | $1,369.47 | $1,864.61 | $3,758.31 |