- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.57 / $1,860.57 / $1,860.57
| Professional | | $1,860.57 | $1,860.57 | $1,860.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,958.00
| Facility | | $2,900.00 | $2,900.00 | $2,958.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $7,878.75
| Professional | | $480.34 | $2,900.00 | $7,878.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.64 / $4,068.52 / $6,450.10
| Professional | | $2,315.64 | $4,068.52 | $6,450.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.57 / $2,860.46 / $4,134.60
| Professional | | $1,860.57 | $2,860.46 | $4,134.60 |