- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.92 / $1,163.92 / $1,163.92
| Professional | | $1,163.92 | $1,163.92 | $1,163.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,649.00 / $2,987.00 / $3,584.00
| Professional | | $2,649.00 | $2,987.00 | $3,584.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.50 / $1,669.60 / $2,780.25
| Professional | | $1,616.50 | $1,669.60 | $2,780.25 |
- 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
- $1,807.29 / $3,780.36 / $4,662.25
| Professional | | $1,807.29 | $3,780.36 | $4,662.25 |