- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.28 / $1,134.28 / $1,134.28
| Professional | | $1,134.28 | $1,134.28 | $1,134.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.00 / $2,515.00 / $3,773.00
| Professional | | $2,096.00 | $2,515.00 | $3,773.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.93 / $1,878.10 / $2,620.89
| Professional | | $1,517.93 | $1,878.10 | $2,620.89 |
- 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
- $1,696.20 / $2,802.07 / $4,474.78
| Professional | | $1,696.20 | $2,802.07 | $4,474.78 |