- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.11 / $1,440.11 / $1,440.11
| Professional | | $1,440.11 | $1,440.11 | $1,440.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.00 / $3,542.00 / $5,701.00
| Professional | | $2,952.00 | $3,542.00 | $5,701.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.45 / $2,392.55 / $3,473.48
| Professional | | $1,835.45 | $2,392.55 | $3,473.48 |
- 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
- $2,060.85 / $3,507.57 / $5,641.69
| Professional | | $2,060.85 | $3,507.57 | $5,641.69 |