- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.86 / $1,231.86 / $1,231.86
| Professional | | $1,231.86 | $1,231.86 | $1,231.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,815.00 / $3,174.00 / $3,809.00
| Professional | | $2,815.00 | $3,174.00 | $3,809.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.45 / $1,853.72 / $2,968.23
| Professional | | $1,774.45 | $1,853.72 | $2,968.23 |
- 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
- $2,064.15 / $4,046.62 / $5,173.07
| Professional | | $2,064.15 | $4,046.62 | $5,173.07 |