- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.16 / $2,039.16 / $2,039.16
| Professional | | $2,039.16 | $2,039.16 | $2,039.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,656.00 / $5,251.00 / $6,301.00
| Professional | | $4,656.00 | $5,251.00 | $6,301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,882.27 / $2,904.41 / $4,896.97
| Professional | | $2,882.27 | $2,904.41 | $4,896.97 |
- 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
- $2,368.03 / $6,461.39 / $8,300.14
| Professional | | $2,368.03 | $6,461.39 | $8,300.14 |