- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.88 / $1,183.88 / $1,183.88
| Professional | | $1,183.88 | $1,183.88 | $1,183.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.00 / $2,729.00 / $3,275.00
| Professional | | $2,047.00 | $2,729.00 | $3,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.75 / $1,496.84 / $2,245.27
| Professional | | $1,000.75 | $1,496.84 | $2,245.27 |
- 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
- $1,162.92 / $1,993.21 / $3,596.70
| Professional | | $1,162.92 | $1,993.21 | $3,596.70 |