- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.62 / $1,558.62 / $1,558.62
| Professional | | $1,558.62 | $1,558.62 | $1,558.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,561.00 / $4,016.00 / $4,819.00
| Professional | | $3,561.00 | $4,016.00 | $4,819.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,338.07 / $2,371.98 / $3,937.43
| Professional | | $2,338.07 | $2,371.98 | $3,937.43 |
- 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
- $2,043.06 / $5,139.68 / $6,706.92
| Professional | | $2,043.06 | $5,139.68 | $6,706.92 |