- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.53 / $1,451.53 / $1,451.53
| Professional | | $1,451.53 | $1,451.53 | $1,451.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.00 / $3,085.00 / $4,504.00
| Professional | | $2,571.00 | $3,085.00 | $4,504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.84 / $2,392.05 / $3,211.90
| Professional | | $1,932.84 | $2,392.05 | $3,211.90 |
- 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
- $2,193.94 / $2,797.26 / $5,185.68
| Professional | | $2,193.94 | $2,797.26 | $5,185.68 |