- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.70 / $1,358.70 / $1,358.70
| Professional | | $1,358.70 | $1,358.70 | $1,358.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,092.00 / $3,486.00 / $4,183.00
| Professional | | $3,092.00 | $3,486.00 | $4,183.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.64 / $2,005.58 / $3,257.07
| Professional | | $1,935.64 | $2,005.58 | $3,257.07 |
- 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
- $1,607.73 / $4,423.64 / $5,557.19
| Professional | | $1,607.73 | $4,423.64 | $5,557.19 |