- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.19 / $1,946.19 / $1,946.19
| Professional | | $1,946.19 | $1,946.19 | $1,946.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,456.00 / $5,025.00 / $6,030.00
| Professional | | $4,456.00 | $5,025.00 | $6,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.30 / $2,550.52 / $4,874.13
| Professional | | $2,537.30 | $2,550.52 | $4,874.13 |
- 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
- $2,856.15 / $5,712.30 / $8,116.67
| Professional | | $2,856.15 | $5,712.30 | $8,116.67 |