- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.22 / $1,389.22 / $1,389.22
| Professional | | $1,389.22 | $1,389.22 | $1,389.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,041.00 / $6,533.00 / $7,840.00
| Professional | | $4,041.00 | $6,533.00 | $7,840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.68 / $1,903.06 / $2,748.87
| Professional | | $1,409.68 | $1,903.06 | $2,748.87 |
- 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
- $1,426.78 / $2,745.02 / $4,445.97
| Professional | | $1,426.78 | $2,745.02 | $4,445.97 |