- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.76 / $1,008.76 / $1,008.76
| Professional | | $1,008.76 | $1,008.76 | $1,008.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.00 / $2,601.00 / $3,121.00
| Professional | | $2,306.00 | $2,601.00 | $3,121.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.20 / $1,667.03 / $2,835.16
| Professional | | $1,550.20 | $1,667.03 | $2,835.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.73 / $3,316.07 / $4,627.93
| Professional | | $1,337.73 | $3,316.07 | $4,627.93 |