- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.46 / $2,419.46 / $2,419.46
| Professional | | $2,419.46 | $2,419.46 | $2,419.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,225.00 / $5,633.00 / $6,760.00
| Professional | | $4,225.00 | $5,633.00 | $6,760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.05 / $3,208.71 / $4,813.07
| Professional | | $2,122.05 | $3,208.71 | $4,813.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,466.38 / $4,139.39 / $7,469.46
| Professional | | $2,466.38 | $4,139.39 | $7,469.46 |