- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.67 / $1,411.67 / $1,411.67
| Professional | | $1,411.67 | $1,411.67 | $1,411.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,061.00 / $6,565.00 / $7,878.00
| Professional | | $4,061.00 | $6,565.00 | $7,878.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.60 / $1,711.28 / $2,471.85
| Professional | | $1,267.60 | $1,711.28 | $2,471.85 |
- 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
- $1,299.83 / $2,846.07 / $4,642.43
| Professional | | $1,299.83 | $2,846.07 | $4,642.43 |