- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.07 / $1,486.07 / $1,486.07
| Professional | | $1,486.07 | $1,486.07 | $1,486.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,397.00 / $3,831.00 / $4,597.00
| Professional | | $3,397.00 | $3,831.00 | $4,597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.78 / $2,304.21 / $3,572.08
| Professional | | $2,149.78 | $2,304.21 | $3,572.08 |
- 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
- $1,927.48 / $4,896.88 / $6,272.65
| Professional | | $1,927.48 | $4,896.88 | $6,272.65 |