- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.29 / $1,226.29 / $1,226.29
| Professional | | $1,226.29 | $1,226.29 | $1,226.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.00 / $2,653.00 / $3,872.00
| Professional | | $2,211.00 | $2,653.00 | $3,872.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.62 / $2,011.19 / $2,914.41
| Professional | | $1,690.62 | $2,011.19 | $2,914.41 |
- 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 / $2,763.07 / $4,906.45
| Professional | | $1,889.80 | $2,763.07 | $4,906.45 |