- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.46 / $1,188.46 / $1,188.46
| Professional | | $1,188.46 | $1,188.46 | $1,188.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.00 / $3,065.00 / $3,678.00
| Professional | | $2,718.00 | $3,065.00 | $3,678.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.17 / $1,953.48 / $3,272.42
| Professional | | $1,802.17 | $1,953.48 | $3,272.42 |
- 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
- $1,506.84 / $3,917.97 / $5,021.28
| Professional | | $1,506.84 | $3,917.97 | $5,021.28 |