- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.92 / $1,615.26 / $2,117.16
| Professional | | $1,127.92 | $1,615.26 | $2,117.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.30 / $1,863.30 / $1,863.30
| Professional | | $1,863.30 | $1,863.30 | $1,863.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.56 / $1,350.00 / $3,090.00
| Professional | | $209.56 | $1,350.00 | $3,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $1,333.56 / $2,262.53
| Professional | | $889.04 | $1,333.56 | $2,262.53 |