- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.00 / $1,150.00 / $1,150.00
| Professional | | $1,150.00 | $1,150.00 | $1,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.00 / $2,694.00 / $3,367.00
| Professional | | $2,245.00 | $2,694.00 | $3,367.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.01 / $1,923.98 / $2,751.95
| Professional | | $1,563.01 | $1,923.98 | $2,751.95 |
- 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
- $1,782.55 / $3,565.10 / $4,466.87
| Professional | | $1,782.55 | $3,565.10 | $4,466.87 |