- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.74 / $1,981.74 / $1,981.74
| Professional | | $1,981.74 | $1,981.74 | $1,981.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,533.00 / $5,112.00 / $6,134.00
| Professional | | $4,533.00 | $5,112.00 | $6,134.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,807.78 / $2,809.02 / $4,733.89
| Professional | | $2,807.78 | $2,809.02 | $4,733.89 |
- 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
- $2,334.87 / $6,273.29 / $8,015.03
| Professional | | $2,334.87 | $6,273.29 | $8,015.03 |