- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.82 / $1,048.82 / $1,048.82
| Professional | | $1,048.82 | $1,048.82 | $1,048.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.00 / $4,135.00 / $4,962.00
| Professional | | $2,673.00 | $4,135.00 | $4,962.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.78 / $1,406.20 / $2,109.30
| Professional | | $931.78 | $1,406.20 | $2,109.30 |
- 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
- $1,105.60 / $1,789.80 / $3,229.65
| Professional | | $1,105.60 | $1,789.80 | $3,229.65 |