- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.94 / $1,936.94 / $1,936.94
| Professional | | $1,936.94 | $1,936.94 | $1,936.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.20 / $1,963.28 / $1,963.28
| Professional | | $1,505.20 | $1,963.28 | $1,963.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $2,601.66
| Facility | | $1,950.00 | $1,950.00 | $2,601.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $2,666.70
| Professional | | $244.82 | $1,950.00 | $2,666.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.17 / $1,936.94 / $1,936.94
| Professional | | $1,437.17 | $1,936.94 | $1,936.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.22 / $1,218.80 / $3,240.65
| Professional | | $837.22 | $1,218.80 | $3,240.65 |