- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.36 / $1,046.36 / $1,046.36
| Professional | | $1,046.36 | $1,046.36 | $1,046.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.00 / $2,413.00 / $2,896.00
| Professional | | $1,809.00 | $2,413.00 | $2,896.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.33 / $1,322.76 / $1,984.14
| Professional | | $895.33 | $1,322.76 | $1,984.14 |
- 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
- $1,047.40 / $1,758.01 / $3,172.29
| Professional | | $1,047.40 | $1,758.01 | $3,172.29 |