- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.04 / $1,416.04 / $1,416.04
| Professional | | $1,416.04 | $1,416.04 | $1,416.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,221.00 / $3,632.00 / $4,358.00
| Professional | | $3,221.00 | $3,632.00 | $4,358.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.37 / $2,006.60 / $3,371.09
| Professional | | $2,000.37 | $2,006.60 | $3,371.09 |
- 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
- $1,651.79 / $3,638.73 / $5,719.56
| Professional | | $1,651.79 | $3,638.73 | $5,719.56 |