- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.05 / $1,067.05 / $1,067.05
| Professional | | $1,067.05 | $1,067.05 | $1,067.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,095.00 / $5,004.00 / $6,005.00
| Professional | | $3,095.00 | $5,004.00 | $6,005.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.75 / $1,334.81 / $1,928.06
| Professional | | $988.75 | $1,334.81 | $1,928.06 |
- 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
- $1,007.56 / $2,215.27 / $3,243.50
| Professional | | $1,007.56 | $2,215.27 | $3,243.50 |