- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.24 / $1,418.24 / $1,418.24
| Professional | | $1,418.24 | $1,418.24 | $1,418.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,081.00 / $6,597.00 / $7,916.00
| Professional | | $4,081.00 | $6,597.00 | $7,916.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.81 / $1,723.70 / $2,489.78
| Professional | | $1,276.81 | $1,723.70 | $2,489.78 |
- 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
- $1,302.20 / $2,613.37 / $4,062.24
| Professional | | $1,302.20 | $2,613.37 | $4,062.24 |