- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.15 / $1,245.15 / $1,245.15
| Professional | | $1,245.15 | $1,245.15 | $1,245.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,228.00 / $2,674.00 / $3,902.00
| Professional | | $2,228.00 | $2,674.00 | $3,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.26 / $2,061.73 / $2,911.35
| Professional | | $1,646.26 | $2,061.73 | $2,911.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.85 / $3,807.81 / $4,905.13
| Professional | | $1,851.85 | $3,807.81 | $4,905.13 |