- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.82 / $1,118.82 / $1,118.82
| Professional | | $1,118.82 | $1,118.82 | $1,118.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.00 / $3,550.00 / $4,260.00
| Professional | | $1,775.00 | $3,550.00 | $4,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.11 / $1,850.77 / $2,530.85
| Professional | | $1,386.11 | $1,850.77 | $2,530.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.50 / $3,344.43 / $4,333.54
| Professional | | $1,578.50 | $3,344.43 | $4,333.54 |