- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.34 / $1,765.34 / $1,765.34
| Professional | | $1,765.34 | $1,765.34 | $1,765.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,041.00 / $4,557.00 / $5,468.00
| Professional | | $4,041.00 | $4,557.00 | $5,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.09 / $2,472.21 / $4,212.95
| Professional | | $2,302.09 | $2,472.21 | $4,212.95 |
- 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
- $2,123.60 / $4,540.93 / $7,296.97
| Professional | | $2,123.60 | $4,540.93 | $7,296.97 |