- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.23 / $1,205.23 / $1,205.23
| Professional | | $1,205.23 | $1,205.23 | $1,205.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.00 / $2,820.00 / $3,526.00
| Professional | | $2,350.00 | $2,820.00 | $3,526.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.71 / $2,014.22 / $2,831.32
| Professional | | $1,638.71 | $2,014.22 | $2,831.32 |
- 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
- $1,894.75 / $3,032.82 / $4,707.12
| Professional | | $1,894.75 | $3,032.82 | $4,707.12 |