- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.78 / $1,151.78 / $1,151.78
| Professional | | $1,151.78 | $1,151.78 | $1,151.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.00 / $2,459.00 / $3,588.00
| Professional | | $2,049.00 | $2,459.00 | $3,588.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.51 / $1,904.52 / $2,508.69
| Professional | | $1,388.51 | $1,904.52 | $2,508.69 |
- 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
- $1,576.86 / $3,153.71 / $4,263.58
| Professional | | $1,576.86 | $3,153.71 | $4,263.58 |