- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.04 / $1,702.04 / $1,702.04
| Professional | | $1,702.04 | $1,702.04 | $1,702.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,152.00 / $4,682.00 / $5,618.00
| Professional | | $4,152.00 | $4,682.00 | $5,618.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,008.16 / $3,008.16 / $3,008.16
| Professional | | $3,008.16 | $3,008.16 | $3,008.16 |
- 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
- $1,401.30 / $3,629.78 / $5,233.64
| Professional | | $1,401.30 | $3,629.78 | $5,233.64 |