- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.22 / $1,253.22 / $1,253.22
| Professional | | $1,253.22 | $1,253.22 | $1,253.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,447.00 / $2,936.00 / $3,671.00
| Professional | | $2,447.00 | $2,936.00 | $3,671.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.87 / $2,098.81 / $2,926.81
| Professional | | $1,690.87 | $2,098.81 | $2,926.81 |
- 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
- $1,967.34 / $3,149.84 / $4,881.35
| Professional | | $1,967.34 | $3,149.84 | $4,881.35 |