- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.59 / $1,212.59 / $1,212.59
| Professional | | $1,212.59 | $1,212.59 | $1,212.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.00 / $3,126.00 / $3,751.00
| Professional | | $2,772.00 | $3,126.00 | $3,751.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.66 / $1,846.73 / $2,928.46
| Professional | | $1,755.66 | $1,846.73 | $2,928.46 |
- 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
- $1,537.15 / $3,994.04 / $5,126.88
| Professional | | $1,537.15 | $3,994.04 | $5,126.88 |