- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.58 / $1,962.58 / $1,962.58
| Professional | | $1,962.58 | $1,962.58 | $1,962.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,015.00 / $4,818.00 / $7,757.00
| Professional | | $4,015.00 | $4,818.00 | $7,757.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.69 / $3,248.48 / $4,720.22
| Professional | | $2,279.69 | $3,248.48 | $4,720.22 |
- 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
- $2,563.56 / $3,954.20 / $6,206.65
| Professional | | $2,563.56 | $3,954.20 | $6,206.65 |