- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,899.72 / $1,899.72 / $1,899.72
| Professional | | $1,899.72 | $1,899.72 | $1,899.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,342.00 / $4,897.00 / $5,876.00
| Professional | | $4,342.00 | $4,897.00 | $5,876.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.97 / $2,804.08 / $4,540.43
| Professional | | $2,705.97 | $2,804.08 | $4,540.43 |
- 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
- $2,355.71 / $5,051.37 / $7,846.06
| Professional | | $2,355.71 | $5,051.37 | $7,846.06 |