- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.49 / $1,453.49 / $1,453.49
| Professional | | $1,453.49 | $1,453.49 | $1,453.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.00 / $3,747.00 / $4,496.00
| Professional | | $3,323.00 | $3,747.00 | $4,496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.11 / $2,162.82 / $3,604.54
| Professional | | $2,064.11 | $2,162.82 | $3,604.54 |
- 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
- $2,306.69 / $3,591.41 / $5,690.52
| Professional | | $2,306.69 | $3,591.41 | $5,690.52 |