- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.64 / $1,223.64 / $1,223.64
| Professional | | $1,223.64 | $1,223.64 | $1,223.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,646.00 / $3,862.00
| Professional | | $2,205.00 | $2,646.00 | $3,862.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.23 / $2,004.71 / $2,905.49
| Professional | | $1,690.23 | $2,004.71 | $2,905.49 |
- 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
- $1,889.80 / $3,056.89 / $4,837.81
| Professional | | $1,889.80 | $3,056.89 | $4,837.81 |