- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.04 / $1,572.04 / $1,572.04
| Professional | | $1,572.04 | $1,572.04 | $1,572.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,812.00 / $3,374.00 / $4,925.00
| Professional | | $2,812.00 | $3,374.00 | $4,925.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.06 / $2,610.83 / $3,301.41
| Professional | | $1,923.06 | $2,610.83 | $3,301.41 |
- 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
- $2,240.69 / $4,481.39 / $5,377.67
| Professional | | $2,240.69 | $4,481.39 | $5,377.67 |