- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.54 / $1,637.54 / $1,637.54
| Professional | | $1,637.54 | $1,637.54 | $1,637.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,752.00 / $4,231.00 / $5,077.00
| Professional | | $3,752.00 | $4,231.00 | $5,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.94 / $2,315.01 / $3,904.44
| Professional | | $2,308.94 | $2,315.01 | $3,904.44 |
- 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
- $1,992.86 / $5,159.00 / $6,654.14
| Professional | | $1,992.86 | $5,159.00 | $6,654.14 |