- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.21 / $2,164.21 / $2,164.21
| Professional | | $2,164.21 | $2,164.21 | $2,164.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,449.00 / $6,898.00 / $8,278.00
| Professional | | $3,449.00 | $6,898.00 | $8,278.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.43 / $3,584.74 / $4,976.80
| Professional | | $2,808.43 | $3,584.74 | $4,976.80 |
- 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
- $3,172.40 / $4,721.51 / $8,510.02
| Professional | | $3,172.40 | $4,721.51 | $8,510.02 |