- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.89 / $1,065.89 / $1,065.89
| Professional | | $1,065.89 | $1,065.89 | $1,065.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.00 / $2,747.00 / $3,296.00
| Professional | | $2,436.00 | $2,747.00 | $3,296.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.69 / $1,597.67 / $2,592.06
| Professional | | $1,536.69 | $1,597.67 | $2,592.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.44 / $3,502.91 / $4,837.81
| Professional | | $1,781.44 | $3,502.91 | $4,837.81 |