- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.78 / $1,072.78 / $1,072.78
| Professional | | $1,072.78 | $1,072.78 | $1,072.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.00 / $2,513.00 / $3,140.00
| Professional | | $2,094.00 | $2,513.00 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.42 / $1,794.71 / $2,803.10
| Professional | | $1,518.42 | $1,794.71 | $2,803.10 |
- 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
- $1,769.35 / $2,878.43 / $4,481.41
| Professional | | $1,769.35 | $2,878.43 | $4,481.41 |