- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.98 / $1,464.98 / $1,464.98
| Professional | | $1,464.98 | $1,464.98 | $1,464.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,581.00 / $3,097.00 / $4,519.00
| Professional | | $2,581.00 | $3,097.00 | $4,519.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.10 / $2,378.83 / $2,701.03
| Professional | | $1,514.10 | $2,378.83 | $2,701.03 |
- 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
- $1,731.95 / $4,093.70 / $5,060.87
| Professional | | $1,731.95 | $4,093.70 | $5,060.87 |