- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.20 / $1,465.20 / $1,465.20
| Professional | | $1,465.20 | $1,465.20 | $1,465.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.00 / $3,172.00 / $4,628.00
| Professional | | $2,643.00 | $3,172.00 | $4,628.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.69 / $2,404.92 / $3,465.13
| Professional | | $2,040.69 | $2,404.92 | $3,465.13 |
- 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
- $2,283.04 / $3,744.14 / $5,877.94
| Professional | | $2,283.04 | $3,744.14 | $5,877.94 |