- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.86 / $1,894.86 / $1,894.86
| Professional | | $1,894.86 | $1,894.86 | $1,894.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,333.00 / $4,886.00 / $5,863.00
| Professional | | $4,333.00 | $4,886.00 | $5,863.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,671.99 / $2,821.61 / $4,662.64
| Professional | | $2,671.99 | $2,821.61 | $4,662.64 |
- 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
- $2,256.23 / $4,925.22 / $7,727.28
| Professional | | $2,256.23 | $4,925.22 | $7,727.28 |