- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.86 / $1,044.86 / $1,044.86
| Professional | | $1,044.86 | $1,044.86 | $1,044.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.00 / $1,991.00 / $3,980.00
| Professional | | $1,659.00 | $1,991.00 | $3,980.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.02 / $1,728.42 / $2,423.01
| Professional | | $1,335.02 | $1,728.42 | $2,423.01 |
- 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
- $1,519.10 / $2,583.80 / $4,161.97
| Professional | | $1,519.10 | $2,583.80 | $4,161.97 |