- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.24 / $1,326.24 / $1,326.24
| Professional | | $1,326.24 | $1,326.24 | $1,326.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,392.00 / $2,870.00 / $4,188.00
| Professional | | $2,392.00 | $2,870.00 | $4,188.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.92 / $2,174.48 / $3,163.53
| Professional | | $1,840.92 | $2,174.48 | $3,163.53 |
- 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
- $2,057.56 / $3,371.45 / $5,320.94
| Professional | | $2,057.56 | $3,371.45 | $5,320.94 |