- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.09 / $1,081.09 / $1,081.09
| Professional | | $1,081.09 | $1,081.09 | $1,081.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.00 / $2,798.00 / $3,358.00
| Professional | | $2,481.00 | $2,798.00 | $3,358.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.41 / $1,592.30 / $2,566.02
| Professional | | $1,484.41 | $1,592.30 | $2,566.02 |
- 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
- $1,661.00 / $2,182.92 / $4,353.35
| Professional | | $1,661.00 | $2,182.92 | $4,353.35 |