- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.10 / $3,729.60 / $3,729.60
| Professional | | $1,136.10 | $3,729.60 | $3,729.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.00 / $5,369.00 / $6,443.00
| Professional | | $3,321.00 | $5,369.00 | $6,443.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.99 / $1,587.59 / $2,293.19
| Professional | | $1,175.99 | $1,587.59 | $2,293.19 |
- 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
- $1,324.46 / $2,524.87 / $4,345.89
| Professional | | $1,324.46 | $2,524.87 | $4,345.89 |