- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.71 / $1,416.71 / $1,416.71
| Professional | | $1,416.71 | $1,416.71 | $1,416.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,238.00 / $3,651.00 / $4,381.00
| Professional | | $3,238.00 | $3,651.00 | $4,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.21 / $2,325.25 / $3,878.85
| Professional | | $2,154.21 | $2,325.25 | $3,878.85 |
- 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
- $2,399.11 / $4,666.43 / $5,982.22
| Professional | | $2,399.11 | $4,666.43 | $5,982.22 |