- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.60 / $1,124.60 / $1,124.60
| Professional | | $1,124.60 | $1,124.60 | $1,124.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.00 / $2,634.00 / $3,292.00
| Professional | | $2,195.00 | $2,634.00 | $3,292.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.11 / $1,880.79 / $2,652.66
| Professional | | $1,528.11 | $1,880.79 | $2,652.66 |
- 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
- $1,760.55 / $2,874.28 / $4,361.27
| Professional | | $1,760.55 | $2,874.28 | $4,361.27 |