- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.69 / $1,039.69 / $1,039.69
| Professional | | $1,039.69 | $1,039.69 | $1,039.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.00 / $2,125.00 / $2,550.00
| Professional | | $2,125.00 | $2,125.00 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.80 / $1,709.81 / $2,384.41
| Professional | | $1,291.80 | $1,709.81 | $2,384.41 |
- 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
- $1,451.99 / $2,436.05 / $3,878.14
| Professional | | $1,451.99 | $2,436.05 | $3,878.14 |