- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.98 / $1,437.98 / $1,437.98
| Professional | | $1,437.98 | $1,437.98 | $1,437.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.00 / $3,204.00 / $4,805.00
| Professional | | $2,670.00 | $3,204.00 | $4,805.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.43 / $2,397.76 / $3,335.60
| Professional | | $1,758.43 | $2,397.76 | $3,335.60 |
- 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
- $1,963.50 / $3,240.32 / $5,170.43
| Professional | | $1,963.50 | $3,240.32 | $5,170.43 |