- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.50 / $1,615.50 / $1,615.50
| Professional | | $1,615.50 | $1,615.50 | $1,615.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,699.00 / $4,171.00 / $5,005.00
| Professional | | $3,699.00 | $4,171.00 | $5,005.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.31 / $2,279.46 / $3,831.53
| Professional | | $2,264.31 | $2,279.46 | $3,831.53 |
- 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
- $1,908.06 / $5,089.70 / $6,524.77
| Professional | | $1,908.06 | $5,089.70 | $6,524.77 |