- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.78 / $1,706.78 / $1,706.78
| Professional | | $1,706.78 | $1,706.78 | $1,706.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,911.00 / $4,410.00 / $5,292.00
| Professional | | $3,911.00 | $4,410.00 | $5,292.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.05 / $2,414.02 / $4,071.27
| Professional | | $2,376.05 | $2,414.02 | $4,071.27 |
- 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
- $2,652.10 / $5,560.32 / $6,857.39
| Professional | | $2,652.10 | $5,560.32 | $6,857.39 |