- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.12 / $1,316.12 / $1,316.12
| Professional | | $1,316.12 | $1,316.12 | $1,316.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.00 / $3,367.00 / $4,040.00
| Professional | | $2,986.00 | $3,367.00 | $4,040.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.98 / $1,879.84 / $3,161.63
| Professional | | $1,857.98 | $1,879.84 | $3,161.63 |
- 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
- $1,621.00 / $3,416.28 / $5,495.18
| Professional | | $1,621.00 | $3,416.28 | $5,495.18 |