- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.09 / $1,368.09 / $1,368.09
| Professional | | $1,368.09 | $1,368.09 | $1,368.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.00 / $3,500.00 / $4,200.00
| Professional | | $3,104.00 | $3,500.00 | $4,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.16 / $1,907.28 / $3,004.05
| Professional | | $1,797.16 | $1,907.28 | $3,004.05 |
- 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
- $1,548.52 / $4,250.39 / $5,487.23
| Professional | | $1,548.52 | $4,250.39 | $5,487.23 |