- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.26 / $1,385.26 / $1,385.26
| Professional | | $1,385.26 | $1,385.26 | $1,385.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.00 / $4,748.00 / $5,698.00
| Professional | | $2,949.00 | $4,748.00 | $5,698.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.22 / $1,507.08 / $2,260.62
| Professional | | $1,275.22 | $1,507.08 | $2,260.62 |
- 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
- $1,050.39 / $1,909.80 / $3,501.29
| Professional | | $1,050.39 | $1,909.80 | $3,501.29 |