- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.61 / $1,304.61 / $1,304.61
| Professional | | $1,304.61 | $1,304.61 | $1,304.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.00 / $2,822.00 / $4,118.00
| Professional | | $2,352.00 | $2,822.00 | $4,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.70 / $2,178.54 / $3,068.81
| Professional | | $1,787.70 | $2,178.54 | $3,068.81 |
- 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
- $2,080.65 / $3,327.46 / $5,148.01
| Professional | | $2,080.65 | $3,327.46 | $5,148.01 |