- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.93 / $1,736.93 / $1,736.93
| Professional | | $1,736.93 | $1,736.93 | $1,736.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,950.00 / $4,454.00 / $5,345.00
| Professional | | $3,950.00 | $4,454.00 | $5,345.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.30 / $2,477.52 / $4,139.71
| Professional | | $2,473.30 | $2,477.52 | $4,139.71 |
- 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
- $2,137.81 / $5,524.21 / $7,059.36
| Professional | | $2,137.81 | $5,524.21 | $7,059.36 |