- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,063.82 / $3,688.92 / $6,000.02
| Professional | | $3,063.82 | $3,688.92 | $6,000.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.00 / $1,191.00 / $1,298.00
| Professional | | $1,191.00 | $1,191.00 | $1,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.40 / $1,033.40 / $1,996.90
| Professional | | $868.40 | $1,033.40 | $1,996.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.35 / $13,851.75 / $26,542.00
| Facility | | $2,211.35 | $13,851.75 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,515.27 / $6,515.27 / $6,515.27
| Professional | | $6,515.27 | $6,515.27 | $6,515.27 |