- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.46 / $1,755.46 / $1,755.46
| Professional | | $1,755.46 | $1,755.46 | $1,755.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,163.00 / $3,796.00 / $5,540.00
| Professional | | $3,163.00 | $3,796.00 | $5,540.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.60 / $2,929.76 / $4,145.52
| Professional | | $2,390.60 | $2,929.76 | $4,145.52 |
- 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
- $2,795.10 / $5,513.04 / $6,893.03
| Professional | | $2,795.10 | $5,513.04 | $6,893.03 |