- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.18 / $1,354.18 / $1,354.18
| Professional | | $1,354.18 | $1,354.18 | $1,354.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,094.00 / $3,489.00 / $4,187.00
| Professional | | $3,094.00 | $3,489.00 | $4,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.53 / $1,904.08 / $3,219.36
| Professional | | $1,898.53 | $1,904.08 | $3,219.36 |
- 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
- $1,604.90 / $4,255.89 / $5,492.50
| Professional | | $1,604.90 | $4,255.89 | $5,492.50 |