- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.65 / $1,271.65 / $1,271.65
| Professional | | $1,271.65 | $1,271.65 | $1,271.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.00 / $3,289.00 / $3,947.00
| Professional | | $2,916.00 | $3,289.00 | $3,947.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.25 / $1,776.82 / $3,021.53
| Professional | | $1,773.25 | $1,776.82 | $3,021.53 |
- 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
- $1,984.39 / $2,863.18 / $5,129.52
| Professional | | $1,984.39 | $2,863.18 | $5,129.52 |