- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.47 / $1,654.47 / $1,654.47
| Professional | | $1,654.47 | $1,654.47 | $1,654.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,760.00 / $4,241.00 / $5,089.00
| Professional | | $3,760.00 | $4,241.00 | $5,089.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.55 / $2,344.57 / $3,949.54
| Professional | | $2,340.55 | $2,344.57 | $3,949.54 |
- 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
- $2,617.44 / $5,391.40 / $6,706.92
| Professional | | $2,617.44 | $5,391.40 | $6,706.92 |