- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.79 / $1,763.79 / $1,763.79
| Professional | | $1,763.79 | $1,763.79 | $1,763.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,176.00 / $3,811.00 / $5,562.00
| Professional | | $3,176.00 | $3,811.00 | $5,562.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.58 / $2,884.85 / $4,197.68
| Professional | | $2,295.58 | $2,884.85 | $4,197.68 |
- 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
- $2,773.65 / $4,483.67 / $7,344.47
| Professional | | $2,773.65 | $4,483.67 | $7,344.47 |