- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.08 / $1,097.08 / $1,097.08
| Professional | | $1,097.08 | $1,097.08 | $1,097.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.00 / $2,548.00 / $3,185.00
| Professional | | $2,123.00 | $2,548.00 | $3,185.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.70 / $1,812.11 / $2,414.33
| Professional | | $1,410.70 | $1,812.11 | $2,414.33 |
- 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
- $1,583.45 / $2,639.40 / $3,989.05
| Professional | | $1,583.45 | $2,639.40 | $3,989.05 |