- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.19 / $1,203.19 / $1,203.19
| Professional | | $1,203.19 | $1,203.19 | $1,203.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,750.00 / $3,101.00 / $3,721.00
| Professional | | $2,750.00 | $3,101.00 | $3,721.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.77 / $1,791.15 / $2,906.10
| Professional | | $1,741.77 | $1,791.15 | $2,906.10 |
- 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
- $1,991.55 / $2,749.10 / $5,041.10
| Professional | | $1,991.55 | $2,749.10 | $5,041.10 |