- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.31 / $1,635.31 / $1,635.31
| Professional | | $1,635.31 | $1,635.31 | $1,635.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.00 / $3,536.00 / $5,161.00
| Professional | | $2,947.00 | $3,536.00 | $5,161.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,286.46 / $2,676.94 / $3,899.88
| Professional | | $2,286.46 | $2,676.94 | $3,899.88 |
- 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
- $2,553.10 / $4,175.72 / $6,578.86
| Professional | | $2,553.10 | $4,175.72 | $6,578.86 |