- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.40 / $1,235.40 / $1,235.40
| Professional | | $1,235.40 | $1,235.40 | $1,235.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,278.00 / $2,734.00 / $4,099.00
| Professional | | $2,278.00 | $2,734.00 | $4,099.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.88 / $2,041.69 / $2,795.19
| Professional | | $1,630.88 | $2,041.69 | $2,795.19 |
- 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
- $1,822.70 / $3,645.41 / $4,807.43
| Professional | | $1,822.70 | $3,645.41 | $4,807.43 |