- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.36 / $1,274.36 / $1,274.36
| Professional | | $1,274.36 | $1,274.36 | $1,274.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,484.00 / $2,981.00 / $3,726.00
| Professional | | $2,484.00 | $2,981.00 | $3,726.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.28 / $2,129.21 / $3,000.98
| Professional | | $1,734.28 | $2,129.21 | $3,000.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.20 / $3,999.45 / $5,004.14
| Professional | | $2,026.20 | $3,999.45 | $5,004.14 |