- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.03 / $1,274.03 / $1,274.03
| Professional | | $1,274.03 | $1,274.03 | $1,274.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,611.00 / $3,133.00 / $5,042.00
| Professional | | $2,611.00 | $3,133.00 | $5,042.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.44 / $2,116.94 / $3,049.43
| Professional | | $1,574.44 | $2,116.94 | $3,049.43 |
- 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
- $1,765.50 / $3,027.84 / $4,913.04
| Professional | | $1,765.50 | $3,027.84 | $4,913.04 |