- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.00 / $1,932.00 / $1,932.00
| Professional | | $1,932.00 | $1,932.00 | $1,932.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,417.00 / $4,981.00 / $5,977.00
| Professional | | $4,417.00 | $4,981.00 | $5,977.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.39 / $2,769.38 / $4,631.03
| Professional | | $2,724.39 | $2,769.38 | $4,631.03 |
- 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
- $2,305.48 / $6,177.59 / $7,892.29
| Professional | | $2,305.48 | $6,177.59 | $7,892.29 |