- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.29 / $1,538.29 / $1,538.29
| Professional | | $1,538.29 | $1,538.29 | $1,538.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,521.00 / $3,971.00 / $4,765.00
| Professional | | $3,521.00 | $3,971.00 | $4,765.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.92 / $2,172.69 / $3,665.38
| Professional | | $2,154.92 | $2,172.69 | $3,665.38 |
- 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
- $1,857.85 / $4,814.71 / $6,194.74
| Professional | | $1,857.85 | $4,814.71 | $6,194.74 |