- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.61 / $1,887.61 / $1,887.61
| Professional | | $1,887.61 | $1,887.61 | $1,887.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,868.00 / $4,642.00 / $7,471.00
| Professional | | $3,868.00 | $4,642.00 | $7,471.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,428.94 / $3,131.94 / $4,520.35
| Professional | | $2,428.94 | $3,131.94 | $4,520.35 |
- 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
- $2,726.90 / $5,903.91 / $7,394.65
| Professional | | $2,726.90 | $5,903.91 | $7,394.65 |