- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.14 / $1,090.14 / $1,090.14
| Professional | | $1,090.14 | $1,090.14 | $1,090.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.00 / $2,510.00 / $3,012.00
| Professional | | $1,883.00 | $2,510.00 | $3,012.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.12 / $1,344.39 / $2,016.59
| Professional | | $898.12 | $1,344.39 | $2,016.59 |
- 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
- $1,042.60 / $1,738.21 / $2,805.00
| Professional | | $1,042.60 | $1,738.21 | $2,805.00 |