- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.04 / $1,187.04 / $1,187.04
| Professional | | $1,187.04 | $1,187.04 | $1,187.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.00 / $2,572.00 / $3,752.00
| Professional | | $2,143.00 | $2,572.00 | $3,752.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.40 / $1,985.64 / $2,784.16
| Professional | | $1,611.40 | $1,985.64 | $2,784.16 |
- 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
- $1,821.60 / $2,665.31 / $4,594.92
| Professional | | $1,821.60 | $2,665.31 | $4,594.92 |