- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.14 / $1,126.14 / $1,126.14
| Professional | | $1,126.14 | $1,126.14 | $1,126.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.00 / $2,903.00 / $3,484.00
| Professional | | $2,574.00 | $2,903.00 | $3,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.17 / $1,724.04 / $2,766.64
| Professional | | $1,630.17 | $1,724.04 | $2,766.64 |
- 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
- $1,471.31 / $3,712.10 / $4,773.12
| Professional | | $1,471.31 | $3,712.10 | $4,773.12 |