- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.03 / $1,152.03 / $1,152.03
| Professional | | $1,152.03 | $1,152.03 | $1,152.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,367.00 / $5,444.00 / $6,533.00
| Professional | | $3,367.00 | $5,444.00 | $6,533.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.86 / $1,601.72 / $2,318.29
| Professional | | $1,188.86 | $1,601.72 | $2,318.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.04 / $2,295.06 / $3,667.28
| Professional | | $1,152.04 | $2,295.06 | $3,667.28 |