- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.11 / $1,637.11 / $1,637.11
| Professional | | $1,637.11 | $1,637.11 | $1,637.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.00 / $3,482.00 / $5,083.00
| Professional | | $2,902.00 | $3,482.00 | $5,083.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.55 / $2,687.03 / $3,245.97
| Professional | | $1,912.55 | $2,687.03 | $3,245.97 |
- 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
- $2,193.94 / $3,821.31 / $6,172.33
| Professional | | $2,193.94 | $3,821.31 | $6,172.33 |