- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.21 / $1,981.21 / $1,981.21
| Professional | | $1,981.21 | $1,981.21 | $1,981.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,523.00 / $4,228.00 / $6,170.00
| Professional | | $3,523.00 | $4,228.00 | $6,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.57 / $3,273.14 / $4,618.88
| Professional | | $2,480.57 | $3,273.14 | $4,618.88 |
- 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
- $2,818.76 / $4,794.08 / $7,729.91
| Professional | | $2,818.76 | $4,794.08 | $7,729.91 |