- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.85 / $1,921.85 / $1,921.85
| Professional | | $1,921.85 | $1,921.85 | $1,921.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,391.00 / $4,952.00 / $5,942.00
| Professional | | $4,391.00 | $4,952.00 | $5,942.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.84 / $2,926.66 / $4,837.46
| Professional | | $2,878.84 | $2,926.66 | $4,837.46 |
- 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
- $3,257.65 / $4,394.84 / $8,267.14
| Professional | | $3,257.65 | $4,394.84 | $8,267.14 |