- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.84 / $1,100.84 / $1,100.84
| Professional | | $1,100.84 | $1,100.84 | $1,100.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.00 / $2,423.00 / $3,634.00
| Professional | | $2,019.00 | $2,423.00 | $3,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.17 / $1,823.24 / $2,456.77
| Professional | | $1,361.17 | $1,823.24 | $2,456.77 |
- 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
- $1,524.05 / $2,551.41 / $4,111.79
| Professional | | $1,524.05 | $2,551.41 | $4,111.79 |