- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.21 / $1,040.21 / $1,040.21
| Professional | | $1,040.21 | $1,040.21 | $1,040.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.00 / $2,548.00 / $4,367.00
| Professional | | $2,123.00 | $2,548.00 | $4,367.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.69 / $1,704.24 / $2,360.39
| Professional | | $1,310.69 | $1,704.24 | $2,360.39 |
- 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
- $1,469.59 / $2,469.25 / $3,944.15
| Professional | | $1,469.59 | $2,469.25 | $3,944.15 |