- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.76 / $2,010.76 / $2,010.76
| Professional | | $2,010.76 | $2,010.76 | $2,010.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,588.00 / $5,173.00 / $6,208.00
| Professional | | $4,588.00 | $5,173.00 | $6,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.57 / $2,836.26 / $4,799.27
| Professional | | $2,832.57 | $2,836.26 | $4,799.27 |
- 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
- $3,160.30 / $6,581.77 / $8,232.86
| Professional | | $3,160.30 | $6,581.77 | $8,232.86 |