- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.59 / $1,022.59 / $1,022.59
| Professional | | $1,022.59 | $1,022.59 | $1,022.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,605.00 / $4,030.00 / $4,836.00
| Professional | | $2,605.00 | $4,030.00 | $4,836.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.50 / $1,292.30 / $1,938.44
| Professional | | $805.50 | $1,292.30 | $1,938.44 |
- 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
- $940.07 / $1,743.00 / $2,947.10
| Professional | | $940.07 | $1,743.00 | $2,947.10 |