- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.15 / $1,311.15 / $1,311.15
| Professional | | $1,311.15 | $1,311.15 | $1,311.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.00 / $3,390.00 / $4,068.00
| Professional | | $3,006.00 | $3,390.00 | $4,068.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.03 / $1,778.21 / $3,253.16
| Professional | | $1,698.03 | $1,778.21 | $3,253.16 |
- 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
- $1,483.62 / $3,970.99 / $5,290.57
| Professional | | $1,483.62 | $3,970.99 | $5,290.57 |