- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.95 / $1,415.95 / $1,415.95
| Professional | | $1,415.95 | $1,415.95 | $1,415.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,238.00 / $3,651.00 / $4,381.00
| Professional | | $3,238.00 | $3,651.00 | $4,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.76 / $1,931.14 / $3,271.29
| Professional | | $1,797.76 | $1,931.14 | $3,271.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.15 / $4,018.31 / $5,254.93
| Professional | | $2,009.15 | $4,018.31 | $5,254.93 |