- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.01 / $1,321.01 / $1,321.01
| Professional | | $1,321.01 | $1,321.01 | $1,321.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,032.00 / $3,419.00 / $4,103.00
| Professional | | $3,032.00 | $3,419.00 | $4,103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.05 / $1,875.68 / $3,139.22
| Professional | | $1,843.05 | $1,875.68 | $3,139.22 |
- 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
- $2,103.75 / $4,207.50 / $5,239.07
| Professional | | $2,103.75 | $4,207.50 | $5,239.07 |