- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.28 / $1,759.28 / $1,759.28
| Professional | | $1,759.28 | $1,759.28 | $1,759.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,453.17 / $5,654.81 / $5,683.08
| Professional | | $4,453.17 | $5,654.81 | $5,683.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,888.11 / $2,888.11 / $3,610.14
| Professional | | $2,888.11 | $2,888.11 | $3,610.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,507.95 / $1,809.54 / $2,362.46
| Facility | | $1,507.95 | $1,809.54 | $2,362.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.95 / $3,216.96 / $13,612.50
| Professional | | $1,507.95 | $3,216.96 | $13,612.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.52 / $3,216.96 / $3,644.21
| Professional | | $2,563.52 | $3,216.96 | $3,644.21 |