- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.27 / $1,038.27 / $1,038.27
| Professional | | $1,038.27 | $1,038.27 | $1,038.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.00 / $2,552.00 / $4,109.00
| Professional | | $2,127.00 | $2,552.00 | $4,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.52 / $1,728.02 / $2,281.46
| Professional | | $1,239.52 | $1,728.02 | $2,281.46 |
- 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
- $1,389.85 / $3,221.01 / $3,461.06
| Professional | | $1,389.85 | $3,221.01 | $3,461.06 |