- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.39 / $1,186.39 / $1,186.39
| Professional | | $1,186.39 | $1,186.39 | $1,186.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.00 / $2,266.00 / $4,530.00
| Professional | | $1,888.00 | $2,266.00 | $4,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.57 / $1,965.21 / $2,774.35
| Professional | | $1,510.57 | $1,965.21 | $2,774.35 |
- 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
- $1,712.70 / $2,567.53 / $4,641.10
| Professional | | $1,712.70 | $2,567.53 | $4,641.10 |