- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.58 / $1,049.58 / $1,049.58
| Professional | | $1,049.58 | $1,049.58 | $1,049.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.00 / $3,350.00 / $4,020.00
| Professional | | $1,675.00 | $3,350.00 | $4,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.45 / $1,742.76 / $2,444.69
| Professional | | $1,359.45 | $1,742.76 | $2,444.69 |
- 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
- $1,541.65 / $2,609.52 / $4,188.35
| Professional | | $1,541.65 | $2,609.52 | $4,188.35 |