- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.49 / $1,265.49 / $1,265.49
| Professional | | $1,265.49 | $1,265.49 | $1,265.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.00 / $2,416.00 / $4,830.00
| Professional | | $2,013.00 | $2,416.00 | $4,830.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.94 / $2,095.25 / $2,717.06
| Professional | | $1,607.94 | $2,095.25 | $2,717.06 |
- 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
- $1,824.34 / $3,085.93 / $4,946.04
| Professional | | $1,824.34 | $3,085.93 | $4,946.04 |