- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.06 / $1,434.06 / $1,434.06
| Professional | | $1,434.06 | $1,434.06 | $1,434.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,278.00 / $3,696.00 / $4,435.00
| Professional | | $3,278.00 | $3,696.00 | $4,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.66 / $2,117.02 / $3,461.25
| Professional | | $2,067.66 | $2,117.02 | $3,461.25 |
- 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
- $2,359.50 / $4,724.59 / $5,992.81
| Professional | | $2,359.50 | $4,724.59 | $5,992.81 |