- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.19 / $1,234.19 / $1,234.19
| Professional | | $1,234.19 | $1,234.19 | $1,234.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,583.00 / $5,792.00 / $6,950.00
| Professional | | $3,583.00 | $5,792.00 | $6,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.23 / $1,509.61 / $2,180.54
| Professional | | $1,118.23 | $1,509.61 | $2,180.54 |
- 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
- $1,156.30 / $2,322.92 / $3,639.99
| Professional | | $1,156.30 | $2,322.92 | $3,639.99 |