- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.34 / $1,960.34 / $1,960.34
| Professional | | $1,960.34 | $1,960.34 | $1,960.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,960.00 / $3,960.00 / $4,316.39
| Professional | | $3,960.00 | $3,960.00 | $4,316.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,745.13 / $5,745.13 / $6,313.96
| Professional | | $5,745.13 | $5,745.13 | $6,313.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,692.50 / $10,061.87 / $10,061.87
| Professional | | $5,692.50 | $10,061.87 | $10,061.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,507.95 / $3,996.07
| Professional | | $1,055.57 | $1,507.95 | $3,996.07 |