- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.31 / $1,324.31 / $1,324.31
| Professional | | $1,324.31 | $1,324.31 | $1,324.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,026.00 / $3,412.00 / $4,094.00
| Professional | | $3,026.00 | $3,412.00 | $4,094.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,705.40 / $1,824.82 / $3,070.02
| Professional | | $1,705.40 | $1,824.82 | $3,070.02 |
- 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
- $1,438.62 / $3,807.10 / $5,064.83
| Professional | | $1,438.62 | $3,807.10 | $5,064.83 |