- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.57 / $1,228.57 / $1,228.57
| Professional | | $1,228.57 | $1,228.57 | $1,228.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,521.00 / $3,025.00 / $4,868.00
| Professional | | $2,521.00 | $3,025.00 | $4,868.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.31 / $2,048.14 / $2,872.87
| Professional | | $1,545.31 | $2,048.14 | $2,872.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.10 / $3,478.20 / $4,774.43
| Professional | | $1,739.10 | $3,478.20 | $4,774.43 |