- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.29 / $1,153.29 / $1,153.29
| Professional | | $1,153.29 | $1,153.29 | $1,153.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.00 / $2,700.00 / $3,374.00
| Professional | | $2,250.00 | $2,700.00 | $3,374.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.73 / $1,927.84 / $2,713.19
| Professional | | $1,566.73 | $1,927.84 | $2,713.19 |
- 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
- $1,823.81 / $2,919.11 / $4,521.01
| Professional | | $1,823.81 | $2,919.11 | $4,521.01 |