- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.27 / $1,182.27 / $1,182.27
| Professional | | $1,182.27 | $1,182.27 | $1,182.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.00 / $2,767.00 / $3,458.00
| Professional | | $2,306.00 | $2,767.00 | $3,458.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.02 / $1,976.03 / $2,902.83
| Professional | | $1,606.02 | $1,976.03 | $2,902.83 |
- 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
- $1,880.99 / $3,002.12 / $4,757.30
| Professional | | $1,880.99 | $3,002.12 | $4,757.30 |