- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.32 / $1,185.32 / $1,185.32
| Professional | | $1,185.32 | $1,185.32 | $1,185.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.00 / $2,621.00 / $3,932.00
| Professional | | $2,184.00 | $2,621.00 | $3,932.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.01 / $1,959.85 / $2,931.90
| Professional | | $1,532.01 | $1,959.85 | $2,931.90 |
- 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
- $1,330.62 / $2,826.16 / $4,524.96
| Professional | | $1,330.62 | $2,826.16 | $4,524.96 |