- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.53 / $1,531.53 / $1,531.53
| Professional | | $1,531.53 | $1,531.53 | $1,531.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,429.00 / $7,161.00 / $8,593.00
| Professional | | $4,429.00 | $7,161.00 | $8,593.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.68 / $1,944.92 / $2,809.33
| Professional | | $1,440.68 | $1,944.92 | $2,809.33 |
- 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
- $1,517.26 / $2,893.38 / $4,630.58
| Professional | | $1,517.26 | $2,893.38 | $4,630.58 |