- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.32 / $1,309.32 / $1,309.32
| Professional | | $1,309.32 | $1,309.32 | $1,309.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,997.00 / $3,380.00 / $4,056.00
| Professional | | $2,997.00 | $3,380.00 | $4,056.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.40 / $2,159.92 / $3,438.07
| Professional | | $1,965.40 | $2,159.92 | $3,438.07 |
- 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
- $1,651.31 / $4,310.64 / $5,487.23
| Professional | | $1,651.31 | $4,310.64 | $5,487.23 |