- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.98 / $1,110.98 / $1,110.98
| Professional | | $1,110.98 | $1,110.98 | $1,110.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.00 / $2,850.00 / $3,420.00
| Professional | | $2,527.00 | $2,850.00 | $3,420.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.93 / $1,566.23 / $2,627.55
| Professional | | $1,562.93 | $1,566.23 | $2,627.55 |
- 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
- $1,747.35 / $3,494.69 / $4,526.28
| Professional | | $1,747.35 | $3,494.69 | $4,526.28 |