- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.11 / $1,447.11 / $1,447.11
| Professional | | $1,447.11 | $1,447.11 | $1,447.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,292.00 / $3,712.00 / $4,454.00
| Professional | | $3,292.00 | $3,712.00 | $4,454.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.01 / $2,062.06 / $3,425.07
| Professional | | $2,055.01 | $2,062.06 | $3,425.07 |
- 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
- $1,745.59 / $3,757.40 / $5,873.99
| Professional | | $1,745.59 | $3,757.40 | $5,873.99 |