- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.45 / $1,013.45 / $1,013.45
| Professional | | $1,013.45 | $1,013.45 | $1,013.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.00 / $1,936.00 / $3,870.00
| Professional | | $1,613.00 | $1,936.00 | $3,870.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,678.71 / $2,374.19
| Professional | | $1,314.00 | $1,678.71 | $2,374.19 |
- 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
- $1,493.25 / $2,524.85 / $4,049.75
| Professional | | $1,493.25 | $2,524.85 | $4,049.75 |