- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.30 / $1,987.18 / $2,036.46
| Professional | | $1,811.30 | $1,987.18 | $2,036.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.75 / $2,490.73 / $2,984.18
| Professional | | $2,349.75 | $2,490.73 | $2,984.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,807.25 / $2,018.05 / $3,254.45
| Facility | | $1,807.25 | $2,018.05 | $3,254.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.39 / $1,665.14 / $1,766.42
| Professional | | $1,566.39 | $1,665.14 | $1,766.42 |