- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.40 / $1,783.40 / $1,783.40
| Professional | | $1,783.40 | $1,783.40 | $1,783.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,152.00 / $3,782.00 / $5,520.00
| Professional | | $3,152.00 | $3,782.00 | $5,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,133.51 / $2,940.70 / $4,113.83
| Professional | | $2,133.51 | $2,940.70 | $4,113.83 |
- 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
- $2,452.44 / $5,325.75 / $6,848.16
| Professional | | $2,452.44 | $5,325.75 | $6,848.16 |