- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.44 / $1,657.44 / $1,657.44
| Professional | | $1,657.44 | $1,657.44 | $1,657.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,785.00 / $4,268.00 / $5,122.00
| Professional | | $3,785.00 | $4,268.00 | $5,122.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.36 / $2,510.71 / $4,220.09
| Professional | | $2,501.36 | $2,510.71 | $4,220.09 |
- 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
- $2,167.65 / $4,516.04 / $6,985.44
| Professional | | $2,167.65 | $4,516.04 | $6,985.44 |