- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.43 / $1,433.43 / $1,433.43
| Professional | | $1,433.43 | $1,433.43 | $1,433.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,581.00 / $3,097.00 / $4,520.00
| Professional | | $2,581.00 | $3,097.00 | $4,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.77 / $2,345.77 / $3,501.42
| Professional | | $2,020.77 | $2,345.77 | $3,501.42 |
- 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
- $2,258.85 / $4,509.39 / $5,773.66
| Professional | | $2,258.85 | $4,509.39 | $5,773.66 |