- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.08 / $1,763.08 / $1,763.08
| Professional | | $1,763.08 | $1,763.08 | $1,763.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,037.00 / $4,552.00 / $5,462.00
| Professional | | $4,037.00 | $4,552.00 | $5,462.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,466.57 / $2,494.29 / $4,207.17
| Professional | | $2,466.57 | $2,494.29 | $4,207.17 |
- 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
- $2,162.44 / $5,508.78 / $7,098.95
| Professional | | $2,162.44 | $5,508.78 | $7,098.95 |