- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.30 / $1,130.30 / $1,130.30
| Professional | | $1,130.30 | $1,130.30 | $1,130.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.00 / $2,778.00 / $4,472.00
| Professional | | $2,315.00 | $2,778.00 | $4,472.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.48 / $1,879.07 / $2,613.46
| Professional | | $1,403.48 | $1,879.07 | $2,613.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $3,905.54 / $10,877.00
| Facility | | $2,607.00 | $3,905.54 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.39 / $3,513.33 / $4,342.81
| Professional | | $1,577.39 | $3,513.33 | $4,342.81 |