- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,795.87 / $1,795.87 / $1,795.87
| Professional | | $1,795.87 | $1,795.87 | $1,795.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,102.00 / $4,626.00 / $5,551.00
| Professional | | $4,102.00 | $4,626.00 | $5,551.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.16 / $2,551.92 / $4,519.31
| Professional | | $2,543.16 | $2,551.92 | $4,519.31 |
- 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
- $2,846.80 / $5,867.99 / $7,300.92
| Professional | | $2,846.80 | $5,867.99 | $7,300.92 |