- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.91 / $1,119.91 / $1,119.91
| Professional | | $1,119.91 | $1,119.91 | $1,119.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.00 / $2,356.00 / $3,437.00
| Professional | | $1,963.00 | $2,356.00 | $3,437.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.11 / $1,741.65 / $1,963.75
| Professional | | $1,122.11 | $1,741.65 | $1,963.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.25 / $2,306.82 / $3,685.44
| Professional | | $1,295.25 | $2,306.82 | $3,685.44 |