- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.33 / $1,150.33 / $1,150.33
| Professional | | $1,150.33 | $1,150.33 | $1,150.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.00 / $2,694.00 / $3,367.00
| Professional | | $2,245.00 | $2,694.00 | $3,367.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.94 / $1,923.98 / $2,701.60
| Professional | | $1,563.94 | $1,923.98 | $2,701.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $10,167.24 / $14,634.00
| Facility | | $4,200.00 | $10,167.24 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.70 / $3,607.53 / $4,506.47
| Professional | | $1,822.70 | $3,607.53 | $4,506.47 |