- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.06 / $1,681.06 / $1,681.06
| Professional | | $1,681.06 | $1,681.06 | $1,681.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,841.00 / $4,331.00 / $5,197.00
| Professional | | $3,841.00 | $4,331.00 | $5,197.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,433.42 / $2,575.92 / $4,074.83
| Professional | | $2,433.42 | $2,575.92 | $4,074.83 |
- 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
- $2,206.02 / $5,541.31 / $7,096.31
| Professional | | $2,206.02 | $5,541.31 | $7,096.31 |