- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.93 / $1,009.93 / $1,009.93
| Professional | | $1,009.93 | $1,009.93 | $1,009.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.00 / $2,188.00 / $3,192.00
| Professional | | $1,823.00 | $2,188.00 | $3,192.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.83 / $1,689.46 / $2,478.57
| Professional | | $1,373.83 | $1,689.46 | $2,478.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.04 / $2,573.83 / $3,973.19
| Professional | | $1,612.04 | $2,573.83 | $3,973.19 |