- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.34 / $1,295.34 / $1,295.34
| Professional | | $1,295.34 | $1,295.34 | $1,295.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.00 / $3,334.00 / $4,001.00
| Professional | | $2,956.00 | $3,334.00 | $4,001.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.64 / $1,911.28 / $3,177.29
| Professional | | $1,888.64 | $1,911.28 | $3,177.29 |
- 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
- $2,130.71 / $4,256.95 / $5,447.63
| Professional | | $2,130.71 | $4,256.95 | $5,447.63 |