- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.57 / $1,138.57 / $1,138.57
| Professional | | $1,138.57 | $1,138.57 | $1,138.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.00 / $2,651.00 / $3,181.00
| Professional | | $1,988.00 | $2,651.00 | $3,181.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.59 / $1,510.11 / $2,265.16
| Professional | | $998.59 | $1,510.11 | $2,265.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.65 / $1,947.60 / $3,514.41
| Professional | | $1,160.65 | $1,947.60 | $3,514.41 |