- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.42 / $1,009.42 / $1,009.42
| Professional | | $1,009.42 | $1,009.42 | $1,009.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.00 / $2,486.00 / $4,002.00
| Professional | | $2,072.00 | $2,486.00 | $4,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.58 / $1,685.13 / $2,349.96
| Professional | | $1,256.58 | $1,685.13 | $2,349.96 |
- 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
- $1,416.25 / $2,236.98 / $3,903.23
| Professional | | $1,416.25 | $2,236.98 | $3,903.23 |