- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.53 / $1,875.53 / $1,875.53
| Professional | | $1,875.53 | $1,875.53 | $1,875.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,286.00 / $4,833.00 / $5,800.00
| Professional | | $4,286.00 | $4,833.00 | $5,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,665.48 / $2,717.43 / $4,571.31
| Professional | | $2,665.48 | $2,717.43 | $4,571.31 |
- 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
- $2,975.49 / $6,190.20 / $7,109.54
| Professional | | $2,975.49 | $6,190.20 | $7,109.54 |