- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.42 / $2,110.42 / $2,110.42
| Professional | | $2,110.42 | $2,110.42 | $2,110.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,095.00 / $5,745.00 / $6,894.00
| Professional | | $5,095.00 | $5,745.00 | $6,894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,691.00 / $3,691.00 / $3,691.00
| Professional | | $3,691.00 | $3,691.00 | $3,691.00 |
- 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
- $2,143.10 / $5,034.62 / $6,682.37
| Professional | | $2,143.10 | $5,034.62 | $6,682.37 |