- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.83 / $1,332.83 / $1,332.83
| Professional | | $1,332.83 | $1,332.83 | $1,332.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,402.00 / $2,882.00 / $4,207.00
| Professional | | $2,402.00 | $2,882.00 | $4,207.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.68 / $2,226.17 / $3,123.84
| Professional | | $1,808.68 | $2,226.17 | $3,123.84 |
- 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
- $2,116.40 / $4,175.93 / $5,219.29
| Professional | | $2,116.40 | $4,175.93 | $5,219.29 |