- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.29 / $1,254.29 / $1,254.29
| Professional | | $1,254.29 | $1,254.29 | $1,254.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.00 / $3,216.00 / $3,859.00
| Professional | | $2,852.00 | $3,216.00 | $3,859.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.30 / $1,778.76 / $2,939.53
| Professional | | $1,740.30 | $1,778.76 | $2,939.53 |
- 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
- $1,480.79 / $3,095.90 / $4,983.00
| Professional | | $1,480.79 | $3,095.90 | $4,983.00 |