- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.82 / $1,326.82 / $1,326.82
| Professional | | $1,326.82 | $1,326.82 | $1,326.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.00 / $2,507.00 / $5,012.00
| Professional | | $2,089.00 | $2,507.00 | $5,012.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.28 / $2,182.53 / $2,933.27
| Professional | | $1,596.28 | $2,182.53 | $2,933.27 |
- 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
- $1,828.74 / $3,122.45 / $5,034.46
| Professional | | $1,828.74 | $3,122.45 | $5,034.46 |