- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.07 / $1,328.07 / $1,328.07
| Professional | | $1,328.07 | $1,328.07 | $1,328.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.00 / $3,434.00 / $4,121.00
| Professional | | $3,045.00 | $3,434.00 | $4,121.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.33 / $1,896.31 / $3,158.20
| Professional | | $1,855.33 | $1,896.31 | $3,158.20 |
- 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
- $2,124.65 / $4,313.99 / $5,425.22
| Professional | | $2,124.65 | $4,313.99 | $5,425.22 |