- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.64 / $1,266.64 / $1,266.64
| Professional | | $1,266.64 | $1,266.64 | $1,266.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,903.00 / $3,273.00 / $3,928.00
| Professional | | $2,903.00 | $3,273.00 | $3,928.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.41 / $1,759.39 / $3,147.62
| Professional | | $1,642.41 | $1,759.39 | $3,147.62 |
- 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
- $1,966.26 / $3,932.51 / $5,322.26
| Professional | | $1,966.26 | $3,932.51 | $5,322.26 |