- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.45 / $2,002.45 / $2,002.45
| Professional | | $2,002.45 | $2,002.45 | $2,002.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,191.00 / $6,382.00 / $7,658.00
| Professional | | $3,191.00 | $6,382.00 | $7,658.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.41 / $3,317.34 / $4,578.62
| Professional | | $2,583.41 | $3,317.34 | $4,578.62 |
- 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
- $2,921.05 / $4,359.14 / $7,859.28
| Professional | | $2,921.05 | $4,359.14 | $7,859.28 |