- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.00 / $1,217.00 / $3,169.50
| Professional | | $1,217.00 | $1,217.00 | $3,169.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,363.10 / $2,363.10 / $2,363.10
| Professional | | $2,363.10 | $2,363.10 | $2,363.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $3,685.49
| Facility | | $3,685.49 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $3,685.49
| Professional | | $3,685.49 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.44 / $290.12 / $2,901.24
| Professional | | $154.44 | $290.12 | $2,901.24 |