- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.60 / $1,650.39 / $1,764.21
| Professional | | $1,517.60 | $1,650.39 | $1,764.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,435.00 / $5,435.00 / $8,152.50
| Professional | | $5,435.00 | $5,435.00 | $8,152.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.60 / $5,435.00 / $5,435.00
| Facility | | $1,517.60 | $5,435.00 | $5,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $1,138.20 / $2,717.50
| Professional | | $796.74 | $1,138.20 | $2,717.50 |