- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,729.60 / $5,621.40 / $6,570.90
| Professional | | $3,729.60 | $5,621.40 | $6,570.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $4,223.00 / $5,068.00
| Professional | | $2,612.00 | $4,223.00 | $5,068.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.84 / $1,239.08 / $1,789.79
| Professional | | $917.84 | $1,239.08 | $1,789.79 |
- 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
- $980.56 / $1,771.97 / $3,143.41
| Professional | | $980.56 | $1,771.97 | $3,143.41 |