- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.69 / $1,319.69 / $1,319.69
| Professional | | $1,319.69 | $1,319.69 | $1,319.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.00 / $2,852.00 / $4,163.00
| Professional | | $2,377.00 | $2,852.00 | $4,163.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.96 / $2,159.85 / $3,142.61
| Professional | | $1,836.96 | $2,159.85 | $3,142.61 |
- 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
- $2,049.29 / $3,356.53 / $5,294.53
| Professional | | $2,049.29 | $3,356.53 | $5,294.53 |