- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.09 / $1,722.09 / $1,722.09
| Professional | | $1,722.09 | $1,722.09 | $1,722.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,062.00 / $3,674.00 / $5,363.00
| Professional | | $3,062.00 | $3,674.00 | $5,363.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.60 / $2,846.25 / $3,638.41
| Professional | | $2,117.60 | $2,846.25 | $3,638.41 |
- 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
- $2,470.05 / $3,713.59 / $5,928.12
| Professional | | $2,470.05 | $3,713.59 | $5,928.12 |