- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.16 / $1,128.16 / $1,128.16
| Professional | | $1,128.16 | $1,128.16 | $1,128.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.00 / $2,501.00 / $3,751.00
| Professional | | $2,084.00 | $2,501.00 | $3,751.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.00 / $1,867.52 / $2,582.05
| Professional | | $1,509.00 | $1,867.52 | $2,582.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.85 / $2,785.48 / $4,444.46
| Professional | | $1,686.85 | $2,785.48 | $4,444.46 |