- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.32 / $1,612.32 / $1,612.32
| Professional | | $1,612.32 | $1,612.32 | $1,612.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,536.00 / $3,043.00 / $6,085.00
| Professional | | $2,536.00 | $3,043.00 | $6,085.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.91 / $2,649.60 / $3,525.61
| Professional | | $1,933.91 | $2,649.60 | $3,525.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.85 / $3,783.13 / $6,101.05
| Professional | | $2,214.85 | $3,783.13 | $6,101.05 |