- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.35 / $1,032.35 / $1,032.35
| Professional | | $1,032.35 | $1,032.35 | $1,032.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.00 / $4,066.00 / $4,879.00
| Professional | | $2,628.00 | $4,066.00 | $4,879.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.38 / $1,375.43 / $2,063.15
| Professional | | $868.38 | $1,375.43 | $2,063.15 |
- 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
- $1,006.01 / $1,783.03 / $3,164.70
| Professional | | $1,006.01 | $1,783.03 | $3,164.70 |