- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.07 / $1,764.07 / $1,764.07
| Professional | | $1,764.07 | $1,764.07 | $1,764.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.00 / $3,786.00 / $5,525.00
| Professional | | $3,155.00 | $3,786.00 | $5,525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.23 / $2,927.42 / $3,913.77
| Professional | | $2,279.23 | $2,927.42 | $3,913.77 |
- 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
- $2,656.50 / $4,008.90 / $6,375.61
| Professional | | $2,656.50 | $4,008.90 | $6,375.61 |