- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.98 / $1,742.98 / $1,742.98
| Professional | | $1,742.98 | $1,742.98 | $1,742.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,982.00 / $4,490.00 / $5,388.00
| Professional | | $3,982.00 | $4,490.00 | $5,388.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.96 / $2,609.85 / $4,298.66
| Professional | | $2,475.96 | $2,609.85 | $4,298.66 |
- 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
- $2,500.66 / $5,529.70 / $6,762.37
| Professional | | $2,500.66 | $5,529.70 | $6,762.37 |