- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.47 / $1,037.47 / $1,037.47
| Professional | | $1,037.47 | $1,037.47 | $1,037.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.00 / $2,216.00 / $3,235.00
| Professional | | $1,847.00 | $2,216.00 | $3,235.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.44 / $1,720.44 / $2,279.71
| Professional | | $1,258.44 | $1,720.44 | $2,279.71 |
- 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
- $1,140.66 / $2,454.30 / $3,954.73
| Professional | | $1,140.66 | $2,454.30 | $3,954.73 |