- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.94 / $1,928.94 / $1,928.94
| Professional | | $1,928.94 | $1,928.94 | $1,928.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.00 / $4,922.00 / $5,906.00
| Professional | | $4,365.00 | $4,922.00 | $5,906.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,760.09 / $3,116.42 / $4,643.46
| Professional | | $2,760.09 | $3,116.42 | $4,643.46 |
- 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
- $3,241.05 / $6,345.70 / $9,187.45
| Professional | | $3,241.05 | $6,345.70 | $9,187.45 |