- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.81 / $1,913.81 / $1,913.81
| Professional | | $1,913.81 | $1,913.81 | $1,913.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,348.00 / $4,903.00 / $5,884.00
| Professional | | $4,348.00 | $4,903.00 | $5,884.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,722.29 / $2,765.51 / $4,585.49
| Professional | | $2,722.29 | $2,765.51 | $4,585.49 |
- 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
- $2,306.44 / $6,177.59 / $7,889.65
| Professional | | $2,306.44 | $6,177.59 | $7,889.65 |