- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.92 / $1,951.92 / $1,951.92
| Professional | | $1,951.92 | $1,951.92 | $1,951.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,463.00 / $5,033.00 / $6,040.00
| Professional | | $4,463.00 | $5,033.00 | $6,040.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.27 / $2,778.46 / $4,680.64
| Professional | | $2,776.27 | $2,778.46 | $4,680.64 |
- 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
- $3,096.49 / $6,388.23 / $7,951.70
| Professional | | $3,096.49 | $6,388.23 | $7,951.70 |