- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.97 / $1,296.97 / $1,296.97
| Professional | | $1,296.97 | $1,296.97 | $1,296.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,963.00 / $3,342.00 / $4,010.00
| Professional | | $2,963.00 | $3,342.00 | $4,010.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.77 / $1,958.86 / $3,153.63
| Professional | | $1,873.77 | $1,958.86 | $3,153.63 |
- 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
- $1,688.27 / $3,730.02 / $5,460.86
| Professional | | $1,688.27 | $3,730.02 | $5,460.86 |