- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.06 / $1,515.06 / $1,515.06
| Professional | | $1,515.06 | $1,515.06 | $1,515.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,472.00 / $3,915.00 / $4,698.00
| Professional | | $3,472.00 | $3,915.00 | $4,698.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.26 / $2,138.52 / $3,608.21
| Professional | | $2,130.26 | $2,138.52 | $3,608.21 |
- 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 / $3,895.18 / $6,392.76
| Professional | | $1,830.37 | $3,895.18 | $6,392.76 |