- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.66 / $1,252.66 / $1,252.66
| Professional | | $1,252.66 | $1,252.66 | $1,252.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,567.00 / $3,080.00 / $4,958.00
| Professional | | $2,567.00 | $3,080.00 | $4,958.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.07 / $2,081.96 / $2,857.00
| Professional | | $1,574.07 | $2,081.96 | $2,857.00 |
- 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
- $1,768.24 / $3,015.38 / $4,861.54
| Professional | | $1,768.24 | $3,015.38 | $4,861.54 |