- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $1,519.06 / $1,519.06
| Professional | | $1,519.06 | $1,519.06 | $1,519.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.00 / $3,257.00 / $4,754.00
| Professional | | $2,714.00 | $3,257.00 | $4,754.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.55 / $2,521.19 / $3,337.18
| Professional | | $1,942.55 | $2,521.19 | $3,337.18 |
- 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
- $2,265.44 / $3,418.77 / $5,437.08
| Professional | | $2,265.44 | $3,418.77 | $5,437.08 |