- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,524.64 / $1,524.64 / $1,524.64
| Professional | | $1,524.64 | $1,524.64 | $1,524.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,487.00 / $3,932.00 / $4,718.00
| Professional | | $3,487.00 | $3,932.00 | $4,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.91 / $2,174.48 / $3,651.21
| Professional | | $2,146.91 | $2,174.48 | $3,651.21 |
- 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
- $1,830.37 / $4,854.30 / $6,188.15
| Professional | | $1,830.37 | $4,854.30 | $6,188.15 |