- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.41 / $1,064.41 / $1,064.41
| Professional | | $1,064.41 | $1,064.41 | $1,064.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.00 / $2,418.00 / $3,658.00
| Professional | | $2,015.00 | $2,418.00 | $3,658.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.34 / $1,749.30 / $2,464.71
| Professional | | $1,381.34 | $1,749.30 | $2,464.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.09 / $2,539.80 / $4,102.57
| Professional | | $1,552.09 | $2,539.80 | $4,102.57 |