- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.98 / $1,757.98 / $1,757.98
| Professional | | $1,757.98 | $1,757.98 | $1,757.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,165.00 / $3,798.00 / $5,543.00
| Professional | | $3,165.00 | $3,798.00 | $5,543.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.19 / $2,873.64 / $4,185.57
| Professional | | $2,493.19 | $2,873.64 | $4,185.57 |
- 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
- $2,936.44 / $3,983.61 / $7,047.49
| Professional | | $2,936.44 | $3,983.61 | $7,047.49 |