- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.17 / $1,086.17 / $1,086.17
| Professional | | $1,086.17 | $1,086.17 | $1,086.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,484.00 / $2,801.00 / $3,361.00
| Professional | | $2,484.00 | $2,801.00 | $3,361.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.92 / $1,657.02 / $2,639.02
| Professional | | $1,572.92 | $1,657.02 | $2,639.02 |
- 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
- $1,371.84 / $3,082.61 / $4,511.78
| Professional | | $1,371.84 | $3,082.61 | $4,511.78 |