- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.27 / $1,787.27 / $1,787.27
| Professional | | $1,787.27 | $1,787.27 | $1,787.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,094.00 / $4,616.00 / $5,539.00
| Professional | | $4,094.00 | $4,616.00 | $5,539.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.94 / $2,528.11 / $4,263.97
| Professional | | $2,525.94 | $2,528.11 | $4,263.97 |
- 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
- $2,822.05 / $5,824.34 / $7,269.24
| Professional | | $2,822.05 | $5,824.34 | $7,269.24 |