- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.61 / $1,506.61 / $1,506.61
| Professional | | $1,506.61 | $1,506.61 | $1,506.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,716.00 / $3,259.00 / $4,757.00
| Professional | | $2,716.00 | $3,259.00 | $4,757.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.71 / $2,515.89 / $3,541.31
| Professional | | $2,049.71 | $2,515.89 | $3,541.31 |
- 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
- $2,399.64 / $3,828.78 / $6,064.09
| Professional | | $2,399.64 | $3,828.78 | $6,064.09 |