- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.31 / $1,811.31 / $1,811.31
| Professional | | $1,811.31 | $1,811.31 | $1,811.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,141.00 / $4,188.00 / $5,026.00
| Professional | | $3,141.00 | $4,188.00 | $5,026.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.57 / $2,177.48 / $3,266.22
| Professional | | $1,539.57 | $2,177.48 | $3,266.22 |
- 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
- $1,793.73 / $3,094.20 / $5,583.42
| Professional | | $1,793.73 | $3,094.20 | $5,583.42 |