- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.22 / $1,100.22 / $1,100.22
| Professional | | $1,100.22 | $1,100.22 | $1,100.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.00 / $4,340.00 / $5,208.00
| Professional | | $2,805.00 | $4,340.00 | $5,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.51 / $1,335.41 / $2,003.12
| Professional | | $1,001.51 | $1,335.41 | $2,003.12 |
- 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
- $1,162.01 / $1,887.60 / $3,159.20
| Professional | | $1,162.01 | $1,887.60 | $3,159.20 |