- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.84 / $1,381.84 / $1,381.84
| Professional | | $1,381.84 | $1,381.84 | $1,381.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,175.00 / $3,580.00 / $4,296.00
| Professional | | $3,175.00 | $3,580.00 | $4,296.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.12 / $1,944.27 / $3,273.14
| Professional | | $1,931.12 | $1,944.27 | $3,273.14 |
- 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
- $1,621.00 / $3,557.38 / $5,575.69
| Professional | | $1,621.00 | $3,557.38 | $5,575.69 |