- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.90 / $1,233.90 / $1,233.90
| Professional | | $1,233.90 | $1,233.90 | $1,233.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,826.00 / $3,187.00 / $3,824.00
| Professional | | $2,826.00 | $3,187.00 | $3,824.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.78 / $1,691.08 / $3,062.19
| Professional | | $1,598.78 | $1,691.08 | $3,062.19 |
- 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
- $1,452.37 / $3,774.10 / $5,059.55
| Professional | | $1,452.37 | $3,774.10 | $5,059.55 |