- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.42 / $1,389.42 / $1,389.42
| Professional | | $1,389.42 | $1,389.42 | $1,389.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,444.00 / $2,933.00 / $4,279.00
| Professional | | $2,444.00 | $2,933.00 | $4,279.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.47 / $2,274.67 / $2,890.63
| Professional | | $1,458.47 | $2,274.67 | $2,890.63 |
- 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
- $1,672.54 / $2,919.81 / $4,469.51
| Professional | | $1,672.54 | $2,919.81 | $4,469.51 |