- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.58 / $1,339.58 / $1,339.58
| Professional | | $1,339.58 | $1,339.58 | $1,339.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,867.00 / $6,252.00 / $7,502.00
| Professional | | $3,867.00 | $6,252.00 | $7,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.10 / $1,676.84 / $2,422.11
| Professional | | $1,242.10 | $1,676.84 | $2,422.11 |
- 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
- $1,276.14 / $2,509.60 / $3,955.89
| Professional | | $1,276.14 | $2,509.60 | $3,955.89 |