- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.83 / $1,071.83 / $1,071.83
| Professional | | $1,071.83 | $1,071.83 | $1,071.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,109.00 / $5,026.00 / $6,031.00
| Professional | | $3,109.00 | $5,026.00 | $6,031.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.40 / $1,341.09 / $1,937.12
| Professional | | $993.40 | $1,341.09 | $1,937.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $7,542.00 / $14,634.00
| Facility | | $4,200.00 | $7,542.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.29 / $2,225.36 / $3,283.80
| Professional | | $1,003.29 | $2,225.36 | $3,283.80 |