- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,953.62 / $1,953.62 / $1,953.62
| Professional | | $1,953.62 | $1,953.62 | $1,953.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,475.00 / $4,170.00 / $6,085.00
| Professional | | $3,475.00 | $4,170.00 | $6,085.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.77 / $3,228.38 / $4,556.13
| Professional | | $2,440.77 | $3,228.38 | $4,556.13 |
- 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
- $2,774.20 / $4,721.87 / $7,617.72
| Professional | | $2,774.20 | $4,721.87 | $7,617.72 |