- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.44 / $1,093.44 / $1,093.44
| Professional | | $1,093.44 | $1,093.44 | $1,093.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,178.00 / $5,137.00 / $6,164.00
| Professional | | $3,178.00 | $5,137.00 | $6,164.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.49 / $1,453.27 / $2,099.16
| Professional | | $1,076.49 | $1,453.27 | $2,099.16 |
- 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
- $1,081.46 / $2,127.21 / $3,342.29
| Professional | | $1,081.46 | $2,127.21 | $3,342.29 |