- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.78 / $1,831.78 / $1,831.78
| Professional | | $1,831.78 | $1,831.78 | $1,831.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,194.00 / $4,729.00 / $5,675.00
| Professional | | $4,194.00 | $4,729.00 | $5,675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,567.19 / $2,569.19 / $4,357.41
| Professional | | $2,567.19 | $2,569.19 | $4,357.41 |
- 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
- $2,205.55 / $5,736.49 / $7,365.61
| Professional | | $2,205.55 | $5,736.49 | $7,365.61 |