- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.58 / $1,390.58 / $1,390.58
| Professional | | $1,390.58 | $1,390.58 | $1,390.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,505.00 / $3,006.00 / $4,387.00
| Professional | | $2,505.00 | $3,006.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,673.86 / $2,276.62 / $2,991.57
| Professional | | $1,673.86 | $2,276.62 | $2,991.57 |
- 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
- $2,127.39 / $3,437.02 / $5,530.82
| Professional | | $2,127.39 | $3,437.02 | $5,530.82 |