- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.72 / $1,411.72 / $1,411.72
| Professional | | $1,411.72 | $1,411.72 | $1,411.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.00 / $3,054.00 / $4,457.00
| Professional | | $2,545.00 | $3,054.00 | $4,457.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.01 / $2,357.59 / $3,317.56
| Professional | | $1,920.01 | $2,357.59 | $3,317.56 |
- 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
- $1,785.38 / $4,019.69 / $5,558.51
| Professional | | $1,785.38 | $4,019.69 | $5,558.51 |