- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.56 / $1,319.56 / $1,319.56
| Professional | | $1,319.56 | $1,319.56 | $1,319.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.00 / $2,808.00 / $4,098.00
| Professional | | $2,340.00 | $2,808.00 | $4,098.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.78 / $2,179.91 / $2,893.78
| Professional | | $1,526.78 | $2,179.91 | $2,893.78 |
- 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
- $1,742.39 / $2,526.31 / $4,819.31
| Professional | | $1,742.39 | $2,526.31 | $4,819.31 |