- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.07 / $1,311.07 / $1,311.07
| Professional | | $1,311.07 | $1,311.07 | $1,311.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,996.00 / $3,379.00 / $4,055.00
| Professional | | $2,996.00 | $3,379.00 | $4,055.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.10 / $2,006.36 / $3,160.78
| Professional | | $1,894.10 | $2,006.36 | $3,160.78 |
- 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
- $1,705.79 / $4,317.37 / $5,446.31
| Professional | | $1,705.79 | $4,317.37 | $5,446.31 |