- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.55 / $1,214.55 / $1,214.55
| Professional | | $1,214.55 | $1,214.55 | $1,214.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,099.00 / $4,794.00 / $5,753.00
| Professional | | $3,099.00 | $4,794.00 | $5,753.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.29 / $1,324.38 / $1,986.57
| Professional | | $1,056.29 | $1,324.38 | $1,986.57 |
- 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
- $1,242.51 / $2,077.19 / $3,297.80
| Professional | | $1,242.51 | $2,077.19 | $3,297.80 |