- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.26 / $1,240.26 / $1,240.26
| Professional | | $1,240.26 | $1,240.26 | $1,240.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.00 / $2,684.00 / $3,918.00
| Professional | | $2,237.00 | $2,684.00 | $3,918.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.76 / $2,073.02 / $2,905.01
| Professional | | $1,684.76 | $2,073.02 | $2,905.01 |
- 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
- $1,414.00 / $3,102.54 / $4,906.45
| Professional | | $1,414.00 | $3,102.54 | $4,906.45 |