- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.83 / $1,814.83 / $1,814.83
| Professional | | $1,814.83 | $1,814.83 | $1,814.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,525.00 / $4,230.00 / $5,287.00
| Professional | | $3,525.00 | $4,230.00 | $5,287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.71 / $3,019.12 / $4,267.70
| Professional | | $2,470.71 | $3,019.12 | $4,267.70 |
- 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
- $2,885.85 / $4,086.03 / $7,116.13
| Professional | | $2,885.85 | $4,086.03 | $7,116.13 |