- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.82 / $1,125.82 / $1,125.82
| Professional | | $1,125.82 | $1,125.82 | $1,125.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.00 / $2,392.00 / $3,491.00
| Professional | | $1,993.00 | $2,392.00 | $3,491.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.16 / $1,856.03 / $2,403.11
| Professional | | $1,277.16 | $1,856.03 | $2,403.11 |
- 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
- $1,454.75 / $2,489.98 / $4,036.56
| Professional | | $1,454.75 | $2,489.98 | $4,036.56 |