- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.46 / $1,187.46 / $1,533.17
| Professional | | $1,187.46 | $1,187.46 | $1,533.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,072.00 / $3,933.00 / $6,086.00
| Professional | | $3,072.00 | $3,933.00 | $6,086.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.50 / $1,980.34 / $3,017.73
| Professional | | $1,445.50 | $1,980.34 | $3,017.73 |
- 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
- $1,970.66 / $3,407.97 / $5,364.49
| Professional | | $1,970.66 | $3,407.97 | $5,364.49 |