- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.35 / $1,881.35 / $1,881.35
| Professional | | $1,881.35 | $1,881.35 | $1,881.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,856.00 / $4,627.00 / $7,448.00
| Professional | | $3,856.00 | $4,627.00 | $7,448.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.59 / $3,123.42 / $4,512.04
| Professional | | $2,405.59 | $3,123.42 | $4,512.04 |
- 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
- $2,700.50 / $4,330.93 / $7,341.83
| Professional | | $2,700.50 | $4,330.93 | $7,341.83 |