- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.09 / $1,659.09 / $1,659.09
| Professional | | $1,659.09 | $1,659.09 | $1,659.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,647.00 / $5,294.00 / $6,353.00
| Professional | | $2,647.00 | $5,294.00 | $6,353.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.19 / $2,753.94 / $3,866.73
| Professional | | $2,162.19 | $2,753.94 | $3,866.73 |
- 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
- $2,453.00 / $4,140.85 / $6,627.73
| Professional | | $2,453.00 | $4,140.85 | $6,627.73 |