- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.18 / $1,246.18 / $1,246.18
| Professional | | $1,246.18 | $1,246.18 | $1,246.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,850.00 / $3,214.00 / $3,857.00
| Professional | | $2,850.00 | $3,214.00 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.77 / $1,710.78 / $2,923.38
| Professional | | $1,653.77 | $1,710.78 | $2,923.38 |
- 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
- $1,430.58 / $3,698.21 / $4,928.85
| Professional | | $1,430.58 | $3,698.21 | $4,928.85 |