- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Professional | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.00 / $2,425.00 / $3,057.29
| Professional | | $1,940.00 | $2,425.00 | $3,057.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.42 / $1,335.42 / $1,335.42
| Facility | | $1,335.42 | $1,335.42 | $1,335.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $2,172.13
| Facility | | $1,751.72 | $1,751.72 | $2,172.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.21 / $2,411.21 / $2,411.21
| Professional | | $2,411.21 | $2,411.21 | $2,411.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $70.00
| Professional | | $30.00 | $30.00 | $70.00 |