- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.82 / $1,840.82 / $1,840.82
| Professional | | $1,840.82 | $1,840.82 | $1,840.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,211.00 / $4,749.00 / $5,699.00
| Professional | | $4,211.00 | $4,749.00 | $5,699.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,401.28 / $2,416.23 / $4,613.22
| Professional | | $2,401.28 | $2,416.23 | $4,613.22 |
- 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
- $2,705.45 / $6,001.14 / $7,686.36
| Professional | | $2,705.45 | $6,001.14 | $7,686.36 |