- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.23 / $1,058.23 / $1,058.23
| Professional | | $1,058.23 | $1,058.23 | $1,058.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.00 / $2,292.00 / $3,346.00
| Professional | | $1,910.00 | $2,292.00 | $3,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.83 / $1,770.57 / $2,471.34
| Professional | | $1,434.83 | $1,770.57 | $2,471.34 |
- 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
- $1,302.67 / $2,679.24 / $4,066.93
| Professional | | $1,302.67 | $2,679.24 | $4,066.93 |