- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.57 / $1,369.57 / $1,369.57
| Professional | | $1,369.57 | $1,369.57 | $1,369.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.00 / $2,964.00 / $4,325.00
| Professional | | $2,470.00 | $2,964.00 | $4,325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.33 / $2,247.59 / $3,272.05
| Professional | | $1,887.33 | $2,247.59 | $3,272.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.44 / $3,075.77 / $5,460.86
| Professional | | $2,111.44 | $3,075.77 | $5,460.86 |