- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.64 / $1,182.64 / $1,182.64
| Professional | | $1,182.64 | $1,182.64 | $1,182.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,689.00 / $3,033.00 / $3,640.00
| Professional | | $2,689.00 | $3,033.00 | $3,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.01 / $1,679.25 / $2,805.97
| Professional | | $1,651.01 | $1,679.25 | $2,805.97 |
- 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
- $1,844.70 / $3,689.41 / $4,781.03
| Professional | | $1,844.70 | $3,689.41 | $4,781.03 |