- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.29 / $1,458.29 / $1,458.29
| Professional | | $1,458.29 | $1,458.29 | $1,458.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,341.00 / $3,768.00 / $4,522.00
| Professional | | $3,341.00 | $3,768.00 | $4,522.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.06 / $2,038.89 / $3,471.55
| Professional | | $2,035.06 | $2,038.89 | $3,471.55 |
- 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
- $1,745.12 / $4,547.41 / $5,901.72
| Professional | | $1,745.12 | $4,547.41 | $5,901.72 |