- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.37 / $1,718.37 / $1,718.37
| Professional | | $1,718.37 | $1,718.37 | $1,718.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,903.00 / $4,401.00 / $5,281.00
| Professional | | $3,903.00 | $4,401.00 | $5,281.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.36 / $2,455.09 / $4,020.56
| Professional | | $2,434.36 | $2,455.09 | $4,020.56 |
- 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
- $2,113.65 / $5,425.19 / $7,009.21
| Professional | | $2,113.65 | $5,425.19 | $7,009.21 |