- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.06 / $1,196.06 / $1,196.06
| Professional | | $1,196.06 | $1,196.06 | $1,196.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.00 / $3,094.00 / $3,713.00
| Professional | | $2,744.00 | $3,094.00 | $3,713.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.22 / $1,681.68 / $2,840.00
| Professional | | $1,638.22 | $1,681.68 | $2,840.00 |
- 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
- $1,381.31 / $3,667.39 / $4,773.12
| Professional | | $1,381.31 | $3,667.39 | $4,773.12 |