- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.54 / $1,145.54 / $1,145.54
| Professional | | $1,145.54 | $1,145.54 | $1,145.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.00 / $2,951.00 / $3,541.00
| Professional | | $2,617.00 | $2,951.00 | $3,541.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.60 / $1,593.17 / $2,725.30
| Professional | | $1,487.60 | $1,593.17 | $2,725.30 |
- 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
- $1,778.15 / $3,728.90 / $4,786.31
| Professional | | $1,778.15 | $3,728.90 | $4,786.31 |