- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.17 / $1,410.17 / $1,410.17
| Professional | | $1,410.17 | $1,410.17 | $1,410.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.00 / $2,928.00 / $4,273.00
| Professional | | $2,440.00 | $2,928.00 | $4,273.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.93 / $2,218.19 / $3,310.29
| Professional | | $1,882.93 | $2,218.19 | $3,310.29 |
- 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
- $2,104.86 / $4,443.35 / $5,517.59
| Professional | | $2,104.86 | $4,443.35 | $5,517.59 |