- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.88 / $1,255.88 / $1,255.88
| Professional | | $1,255.88 | $1,255.88 | $1,255.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.00 / $3,237.00 / $3,884.00
| Professional | | $2,870.00 | $3,237.00 | $3,884.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.70 / $2,008.84 / $3,134.09
| Professional | | $1,853.70 | $2,008.84 | $3,134.09 |
- 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
- $2,192.98 / $4,089.12 / $5,504.41
| Professional | | $2,192.98 | $4,089.12 | $5,504.41 |