- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.03 / $1,718.03 / $1,718.03
| Professional | | $1,718.03 | $1,718.03 | $1,718.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,094.00 / $3,713.00 / $5,419.00
| Professional | | $3,094.00 | $3,713.00 | $5,419.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,363.01 / $2,812.19 / $4,084.35
| Professional | | $2,363.01 | $2,812.19 | $4,084.35 |
- 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
- $2,637.26 / $5,274.51 / $6,838.93
| Professional | | $2,637.26 | $5,274.51 | $6,838.93 |