- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.54 / $1,374.54 / $1,374.54
| Professional | | $1,374.54 | $1,374.54 | $1,374.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,145.00 / $3,546.00 / $4,255.00
| Professional | | $3,145.00 | $3,546.00 | $4,255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.04 / $1,948.45 / $3,276.86
| Professional | | $1,939.04 | $1,948.45 | $3,276.86 |
- 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
- $1,649.90 / $3,565.69 / $5,595.46
| Professional | | $1,649.90 | $3,565.69 | $5,595.46 |