- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.31 / $1,779.31 / $1,779.31
| Professional | | $1,779.31 | $1,779.31 | $1,779.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,071.00 / $4,591.00 / $5,509.00
| Professional | | $4,071.00 | $4,591.00 | $5,509.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.86 / $2,462.69 / $4,232.45
| Professional | | $2,301.86 | $2,462.69 | $4,232.45 |
- 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
- $2,751.10 / $4,018.52 / $7,027.67
| Professional | | $2,751.10 | $4,018.52 | $7,027.67 |