- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.98 / $1,196.98 / $1,196.98
| Professional | | $1,196.98 | $1,196.98 | $1,196.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.00 / $2,648.00 / $3,972.00
| Professional | | $2,207.00 | $2,648.00 | $3,972.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $1,980.16 / $2,890.03
| Professional | | $1,494.94 | $1,980.16 | $2,890.03 |
- 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
- $1,745.71 / $3,676.80 / $4,431.22
| Professional | | $1,745.71 | $3,676.80 | $4,431.22 |