- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.08 / $1,172.08 / $1,172.08
| Professional | | $1,172.08 | $1,172.08 | $1,172.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.00 / $2,594.00 / $3,892.00
| Professional | | $2,162.00 | $2,594.00 | $3,892.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.72 / $1,938.04 / $2,657.63
| Professional | | $1,546.72 | $1,938.04 | $2,657.63 |
- 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
- $1,729.19 / $2,605.56 / $4,554.01
| Professional | | $1,729.19 | $2,605.56 | $4,554.01 |