- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,323.34 / $4,323.34 / $5,179.85
| Professional | | $4,323.34 | $4,323.34 | $5,179.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $178.00
| Professional | | $170.00 | $170.00 | $178.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.36 / $2,310.03 / $3,003.62
| Facility | | $1,409.36 | $2,310.03 | $3,003.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.12 / $2,546.12 / $2,546.12
| Professional | | $2,546.12 | $2,546.12 | $2,546.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,394.65 / $2,310.03 / $3,003.62
| Facility | | $1,394.65 | $2,310.03 | $3,003.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.12 / $2,546.12 / $2,546.12
| Professional | | $2,546.12 | $2,546.12 | $2,546.12 |