- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.42 / $1,621.42 / $1,621.42
| Professional | | $1,621.42 | $1,621.42 | $1,621.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,320.00 / $3,984.00 / $6,413.00
| Professional | | $3,320.00 | $3,984.00 | $6,413.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.42 / $2,686.88 / $3,904.16
| Professional | | $2,035.42 | $2,686.88 | $3,904.16 |
- 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
- $2,280.30 / $5,071.32 / $6,285.84
| Professional | | $2,280.30 | $5,071.32 | $6,285.84 |