- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.08 / $1,868.08 / $1,868.08
| Professional | | $1,868.08 | $1,868.08 | $1,868.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,268.00 / $4,813.00 / $5,776.00
| Professional | | $4,268.00 | $4,813.00 | $5,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.97 / $2,831.10 / $4,507.68
| Professional | | $2,705.97 | $2,831.10 | $4,507.68 |
- 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
- $2,434.81 / $6,162.24 / $7,876.43
| Professional | | $2,434.81 | $6,162.24 | $7,876.43 |