- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.14 / $1,378.14 / $1,378.14
| Professional | | $1,378.14 | $1,378.14 | $1,378.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.00 / $3,388.00 / $5,453.00
| Professional | | $2,823.00 | $3,388.00 | $5,453.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.92 / $2,287.71 / $3,234.26
| Professional | | $1,757.92 | $2,287.71 | $3,234.26 |
- 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
- $1,974.50 / $3,353.21 / $5,378.99
| Professional | | $1,974.50 | $3,353.21 | $5,378.99 |