- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.59 / $1,450.59 / $1,450.59
| Professional | | $1,450.59 | $1,450.59 | $1,450.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.00 / $3,132.00 / $4,571.00
| Professional | | $2,610.00 | $3,132.00 | $4,571.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.23 / $2,412.42 / $3,269.87
| Professional | | $1,939.23 | $2,412.42 | $3,269.87 |
- 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
- $2,246.19 / $3,550.74 / $5,550.60
| Professional | | $2,246.19 | $3,550.74 | $5,550.60 |