- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.67 / $1,313.67 / $1,313.67
| Professional | | $1,313.67 | $1,313.67 | $1,313.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.00 / $1,881.00 / $2,319.00
| Professional | | $1,881.00 | $1,881.00 | $2,319.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.79 / $1,855.71 / $2,826.20
| Professional | | $1,770.79 | $1,855.71 | $2,826.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,732.00 / $12,732.00 / $31,027.00
| Facility | | $12,732.00 | $12,732.00 | $31,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.42 / $2,600.29 / $5,028.38
| Professional | | $1,595.42 | $2,600.29 | $5,028.38 |