- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.24 / $1,361.24 / $1,361.24
| Professional | | $1,361.24 | $1,361.24 | $1,361.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.00 / $3,348.00 / $5,390.00
| Professional | | $2,790.00 | $3,348.00 | $5,390.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.31 / $2,263.21 / $2,932.30
| Professional | | $1,733.31 | $2,263.21 | $2,932.30 |
- 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
- $1,459.00 / $3,310.04 / $5,312.99
| Professional | | $1,459.00 | $3,310.04 | $5,312.99 |