- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.42 / $1,656.42 / $1,656.42
| Professional | | $1,656.42 | $1,656.42 | $1,656.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,796.00 / $4,280.00 / $5,136.00
| Professional | | $3,796.00 | $4,280.00 | $5,136.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,314.00 / $2,341.04 / $3,950.83
| Professional | | $2,314.00 | $2,341.04 | $3,950.83 |
- 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
- $2,615.81 / $5,395.86 / $6,685.78
| Professional | | $2,615.81 | $5,395.86 | $6,685.78 |