- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.82 / $1,381.82 / $1,381.82
| Professional | | $1,381.82 | $1,381.82 | $1,381.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.00 / $3,234.00 / $4,043.00
| Professional | | $2,695.00 | $3,234.00 | $4,043.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.66 / $2,309.69 / $3,245.45
| Professional | | $1,882.66 | $2,309.69 | $3,245.45 |
- 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
- $2,193.94 / $3,510.89 / $5,438.40
| Professional | | $2,193.94 | $3,510.89 | $5,438.40 |