- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.19 / $1,095.19 / $1,095.19
| Professional | | $1,095.19 | $1,095.19 | $1,095.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.00 / $2,557.00 / $3,197.00
| Professional | | $2,131.00 | $2,557.00 | $3,197.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.22 / $1,796.11 / $2,579.14
| Professional | | $1,396.22 | $1,796.11 | $2,579.14 |
- 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
- $1,563.65 / $2,448.48 / $3,695.91
| Professional | | $1,563.65 | $2,448.48 | $3,695.91 |