- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.44 / $1,603.44 / $1,603.44
| Professional | | $1,603.44 | $1,603.44 | $1,603.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,891.00 / $3,469.00 / $5,063.00
| Professional | | $2,891.00 | $3,469.00 | $5,063.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.21 / $2,677.79 / $3,877.72
| Professional | | $2,181.21 | $2,677.79 | $3,877.72 |
- 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
- $2,547.04 / $5,032.32 / $6,288.47
| Professional | | $2,547.04 | $5,032.32 | $6,288.47 |