- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.81 / $1,792.81 / $1,792.81
| Professional | | $1,792.81 | $1,792.81 | $1,792.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,673.00 / $4,408.00 / $7,096.00
| Professional | | $3,673.00 | $4,408.00 | $7,096.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.10 / $2,975.16 / $4,199.66
| Professional | | $2,081.10 | $2,975.16 | $4,199.66 |
- 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
- $2,498.10 / $4,305.22 / $7,021.08
| Professional | | $2,498.10 | $4,305.22 | $7,021.08 |