- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.45 / $1,737.45 / $1,737.45
| Professional | | $1,737.45 | $1,737.45 | $1,737.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,964.00 / $4,470.00 / $5,364.00
| Professional | | $3,964.00 | $4,470.00 | $5,364.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.76 / $2,416.73 / $3,902.38
| Professional | | $2,285.76 | $2,416.73 | $3,902.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.17 / $5,366.90 / $6,440.26
| Professional | | $2,311.17 | $5,366.90 | $6,440.26 |