- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.93 / $1,009.93 / $1,009.93
| Professional | | $1,009.93 | $1,009.93 | $1,009.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.00 / $2,188.00 / $3,193.00
| Professional | | $1,823.00 | $2,188.00 | $3,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.08 / $1,690.04 / $2,374.16
| Professional | | $1,378.08 | $1,690.04 | $2,374.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.85 / $2,841.08 / $3,915.14
| Professional | | $1,609.85 | $2,841.08 | $3,915.14 |