- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.64 / $1,452.64 / $1,452.64
| Professional | | $1,452.64 | $1,452.64 | $1,452.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.00 / $3,398.00 / $4,248.00
| Professional | | $2,832.00 | $3,398.00 | $4,248.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.41 / $2,426.79 / $3,417.48
| Professional | | $1,975.41 | $2,426.79 | $3,417.48 |
- 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
- $2,311.65 / $3,688.51 / $5,699.75
| Professional | | $2,311.65 | $3,688.51 | $5,699.75 |