- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.46 / $1,462.46 / $1,462.46
| Professional | | $1,462.46 | $1,462.46 | $1,462.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.00 / $3,416.00 / $4,270.00
| Professional | | $2,847.00 | $3,416.00 | $4,270.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.47 / $2,439.69 / $3,436.10
| Professional | | $1,988.47 | $2,439.69 | $3,436.10 |
- 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
- $2,320.44 / $3,706.79 / $5,730.11
| Professional | | $2,320.44 | $3,706.79 | $5,730.11 |