- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.73 / $1,951.73 / $1,951.73
| Professional | | $1,951.73 | $1,951.73 | $1,951.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,457.00 / $5,026.00 / $6,031.00
| Professional | | $4,457.00 | $5,026.00 | $6,031.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,778.16 / $2,800.81 / $4,685.37
| Professional | | $2,778.16 | $2,800.81 | $4,685.37 |
- 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
- $2,428.66 / $6,235.88 / $7,978.07
| Professional | | $2,428.66 | $6,235.88 | $7,978.07 |