- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.33 / $1,422.33 / $1,422.33
| Professional | | $1,422.33 | $1,422.33 | $1,422.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.00 / $3,323.00 / $4,153.00
| Professional | | $2,769.00 | $3,323.00 | $4,153.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.07 / $2,333.75 / $3,210.00
| Professional | | $1,812.07 | $2,333.75 | $3,210.00 |
- 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
- $2,030.05 / $3,280.99 / $5,401.45
| Professional | | $2,030.05 | $3,280.99 | $5,401.45 |