- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.26 / $1,490.26 / $1,490.26
| Professional | | $1,490.26 | $1,490.26 | $1,490.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,051.00 / $3,661.00 / $5,893.00
| Professional | | $3,051.00 | $3,661.00 | $5,893.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.29 / $2,263.92 / $2,721.14
| Professional | | $1,509.29 | $2,263.92 | $2,721.14 |
- 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
- $1,799.05 / $3,317.86 / $4,988.28
| Professional | | $1,799.05 | $3,317.86 | $4,988.28 |