- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.89 / $1,213.89 / $1,213.89
| Professional | | $1,213.89 | $1,213.89 | $1,213.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.00 / $2,582.00 / $3,768.00
| Professional | | $2,152.00 | $2,582.00 | $3,768.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.76 / $2,002.45 / $2,606.96
| Professional | | $1,414.76 | $2,002.45 | $2,606.96 |
- 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
- $1,610.95 / $2,273.46 / $4,410.13
| Professional | | $1,610.95 | $2,273.46 | $4,410.13 |