- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.44 / $1,634.44 / $1,634.44
| Professional | | $1,634.44 | $1,634.44 | $1,634.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.00 / $3,988.00 / $6,835.00
| Professional | | $3,323.00 | $3,988.00 | $6,835.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,409.01 / $2,647.59 / $4,537.60
| Professional | | $2,409.01 | $2,647.59 | $4,537.60 |
- 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
- $2,696.10 / $5,220.72 / $6,372.59
| Professional | | $2,696.10 | $5,220.72 | $6,372.59 |