- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.73 / $2,171.73 / $2,171.73
| Professional | | $2,171.73 | $2,171.73 | $2,171.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,447.00 / $5,336.00 / $8,591.00
| Professional | | $4,447.00 | $5,336.00 | $8,591.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,811.91 / $3,597.20 / $5,175.35
| Professional | | $2,811.91 | $3,597.20 | $5,175.35 |
- 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
- $3,153.14 / $5,341.04 / $8,539.07
| Professional | | $3,153.14 | $5,341.04 | $8,539.07 |