- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.42 / $1,427.42 / $1,427.42
| Professional | | $1,427.42 | $1,427.42 | $1,427.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,909.00 / $3,491.00 / $5,620.00
| Professional | | $2,909.00 | $3,491.00 | $5,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,922.59 / $2,388.91 / $3,390.43
| Professional | | $1,922.59 | $2,388.91 | $3,390.43 |
- 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
- $2,157.11 / $4,314.21 / $5,798.75
| Professional | | $2,157.11 | $4,314.21 | $5,798.75 |