- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.04 / $1,013.04 / $1,013.04
| Professional | | $1,013.04 | $1,013.04 | $1,013.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.00 / $2,610.00 / $3,132.00
| Professional | | $2,315.00 | $2,610.00 | $3,132.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.38 / $1,528.33 / $2,486.48
| Professional | | $1,461.38 | $1,528.33 | $2,486.48 |
- 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
- $1,703.90 / $3,330.61 / $4,264.89
| Professional | | $1,703.90 | $3,330.61 | $4,264.89 |