- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.88 / $1,610.88 / $1,610.88
| Professional | | $1,610.88 | $1,610.88 | $1,610.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,682.00 / $4,152.00 / $4,982.00
| Professional | | $3,682.00 | $4,152.00 | $4,982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.82 / $2,447.23 / $3,897.26
| Professional | | $2,332.82 | $2,447.23 | $3,897.26 |
- 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
- $2,725.25 / $5,313.09 / $6,999.94
| Professional | | $2,725.25 | $5,313.09 | $6,999.94 |