- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.91 / $1,100.91 / $1,100.91
| Professional | | $1,100.91 | $1,100.91 | $1,100.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.00 / $2,907.00 / $3,488.00
| Professional | | $2,578.00 | $2,907.00 | $3,488.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.72 / $1,546.89 / $2,600.34
| Professional | | $1,503.72 | $1,546.89 | $2,600.34 |
- 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
- $1,277.57 / $3,363.79 / $4,356.00
| Professional | | $1,277.57 | $3,363.79 | $4,356.00 |