- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.04 / $1,032.04 / $1,032.04
| Professional | | $1,032.04 | $1,032.04 | $1,032.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.00 / $2,662.00 / $3,194.00
| Professional | | $2,361.00 | $2,662.00 | $3,194.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.01 / $1,489.05 / $2,539.25
| Professional | | $1,317.01 | $1,489.05 | $2,539.25 |
- 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
- $1,132.14 / $2,942.50 / $4,326.95
| Professional | | $1,132.14 | $2,942.50 | $4,326.95 |