- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.90 / $1,652.90 / $2,894.70
| Professional | | $1,652.90 | $1,652.90 | $2,894.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.30 / $3,228.30 / $3,228.30
| Professional | | $3,228.30 | $3,228.30 | $3,228.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $2,722.29
| Facility | | $1,440.00 | $1,440.00 | $2,722.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,440.00
| Professional | | $1,440.00 | $1,440.00 | $1,440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.14 / $1,391.26 / $2,111.73
| Professional | | $1,188.14 | $1,391.26 | $2,111.73 |