- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.70 / $1,049.70 / $1,049.70
| Professional | | $1,049.70 | $1,049.70 | $1,049.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.00 / $2,745.00 / $3,294.00
| Professional | | $2,434.00 | $2,745.00 | $3,294.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.14 / $1,485.54 / $2,504.77
| Professional | | $1,477.14 | $1,485.54 | $2,504.77 |
- 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
- $1,252.93 / $3,302.19 / $4,263.58
| Professional | | $1,252.93 | $3,302.19 | $4,263.58 |