- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.58 / $1,171.58 / $1,171.58
| Professional | | $1,171.58 | $1,171.58 | $1,171.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,439.00 / $5,560.00 / $6,672.00
| Professional | | $3,439.00 | $5,560.00 | $6,672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.05 / $1,630.87 / $2,355.69
| Professional | | $1,208.05 | $1,630.87 | $2,355.69 |
- 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
- $1,872.64 / $2,594.71 / $3,767.41
| Professional | | $1,872.64 | $2,594.71 | $3,767.41 |