- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.32 / $1,281.32 / $1,281.32
| Professional | | $1,281.32 | $1,281.32 | $1,281.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.00 / $2,985.00 / $3,582.00
| Professional | | $2,239.00 | $2,985.00 | $3,582.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.09 / $1,743.87 / $2,547.73
| Professional | | $1,422.09 | $1,743.87 | $2,547.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.06 / $2,283.23 / $4,862.01
| Professional | | $1,572.06 | $2,283.23 | $4,862.01 |