- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.85 / $1,530.85 / $1,530.85
| Professional | | $1,530.85 | $1,530.85 | $1,530.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.00 / $2,928.00 / $5,857.00
| Professional | | $2,440.00 | $2,928.00 | $5,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.28 / $2,536.42 / $3,690.34
| Professional | | $1,959.28 | $2,536.42 | $3,690.34 |
- 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
- $2,211.55 / $3,818.82 / $6,110.28
| Professional | | $2,211.55 | $3,818.82 | $6,110.28 |