- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.42 / $1,782.42 / $1,782.42
| Professional | | $1,782.42 | $1,782.42 | $1,782.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,211.00 / $3,853.00 / $5,623.00
| Professional | | $3,211.00 | $3,853.00 | $5,623.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.77 / $2,917.33 / $4,255.30
| Professional | | $2,500.77 | $2,917.33 | $4,255.30 |
- 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
- $2,793.99 / $4,579.10 / $7,256.05
| Professional | | $2,793.99 | $4,579.10 | $7,256.05 |