- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.83 / $1,045.83 / $1,045.83
| Professional | | $1,045.83 | $1,045.83 | $1,045.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.00 / $2,424.00 / $2,909.00
| Professional | | $1,818.00 | $2,424.00 | $2,909.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.85 / $1,424.12 / $2,136.17
| Professional | | $1,056.85 | $1,424.12 | $2,136.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.48 / $1,796.40 / $3,318.71
| Professional | | $1,257.48 | $1,796.40 | $3,318.71 |