- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.06 / $1,229.06 / $1,229.06
| Professional | | $1,229.06 | $1,229.06 | $1,229.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,399.00 / $2,879.00 / $3,599.00
| Professional | | $2,399.00 | $2,879.00 | $3,599.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.74 / $2,056.59 / $2,882.44
| Professional | | $1,664.74 | $2,056.59 | $2,882.44 |
- 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
- $1,940.41 / $3,103.37 / $4,802.17
| Professional | | $1,940.41 | $3,103.37 | $4,802.17 |