- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.21 / $1,870.21 / $1,870.21
| Professional | | $1,870.21 | $1,870.21 | $1,870.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,276.00 / $4,822.00 / $5,786.00
| Professional | | $4,276.00 | $4,822.00 | $5,786.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.09 / $2,779.95 / $4,482.93
| Professional | | $2,659.09 | $2,779.95 | $4,482.93 |
- 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
- $2,228.75 / $6,119.71 / $7,636.22
| Professional | | $2,228.75 | $6,119.71 | $7,636.22 |