- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.15 / $1,855.15 / $1,855.15
| Professional | | $1,855.15 | $1,855.15 | $1,855.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,214.00 / $4,753.00 / $5,704.00
| Professional | | $4,214.00 | $4,753.00 | $5,704.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.24 / $2,645.86 / $4,425.76
| Professional | | $2,641.24 | $2,645.86 | $4,425.76 |
- 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
- $2,224.50 / $5,903.70 / $7,570.21
| Professional | | $2,224.50 | $5,903.70 | $7,570.21 |