- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.53 / $1,140.53 / $1,140.53
| Professional | | $1,140.53 | $1,140.53 | $1,140.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,826.00 / $3,391.00 / $5,459.00
| Professional | | $2,826.00 | $3,391.00 | $5,459.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.89 / $2,289.96 / $3,311.14
| Professional | | $1,404.89 | $2,289.96 | $3,311.14 |
- 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
- $1,807.29 / $2,772.19 / $5,204.75
| Professional | | $1,807.29 | $2,772.19 | $5,204.75 |