- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,864.52 / $1,864.52 / $1,864.52
| Professional | | $1,864.52 | $1,864.52 | $1,864.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,258.00 / $4,801.00 / $5,761.00
| Professional | | $4,258.00 | $4,801.00 | $5,761.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.28 / $2,648.88 / $4,726.35
| Professional | | $2,632.28 | $2,648.88 | $4,726.35 |
- 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
- $2,193.71 / $5,897.11 / $7,593.95
| Professional | | $2,193.71 | $5,897.11 | $7,593.95 |