- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.84 / $1,246.84 / $1,246.84
| Professional | | $1,246.84 | $1,246.84 | $1,246.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.00 / $2,652.00 / $3,870.00
| Professional | | $2,210.00 | $2,652.00 | $3,870.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.52 / $2,056.07 / $2,733.78
| Professional | | $1,482.52 | $2,056.07 | $2,733.78 |
- 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
- $1,687.95 / $2,853.54 / $4,564.56
| Professional | | $1,687.95 | $2,853.54 | $4,564.56 |