- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.86 / $2,183.86 / $2,183.86
| Professional | | $2,183.86 | $2,183.86 | $2,183.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,471.00 / $5,365.00 / $8,636.00
| Professional | | $4,471.00 | $5,365.00 | $8,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.67 / $3,616.79 / $5,260.92
| Professional | | $2,816.67 | $3,616.79 | $5,260.92 |
- 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
- $3,158.65 / $5,349.35 / $8,552.29
| Professional | | $3,158.65 | $5,349.35 | $8,552.29 |