- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.72 / $1,274.72 / $1,274.72
| Professional | | $1,274.72 | $1,274.72 | $1,274.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.00 / $3,136.00 / $5,047.00
| Professional | | $2,613.00 | $3,136.00 | $5,047.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.00 / $2,118.51 / $3,008.73
| Professional | | $1,607.00 | $2,118.51 | $3,008.73 |
- 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
- $1,804.55 / $3,969.12 / $4,951.32
| Professional | | $1,804.55 | $3,969.12 | $4,951.32 |