- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.80 / $1,558.80 / $1,558.80
| Professional | | $1,558.80 | $1,558.80 | $1,558.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,533.00 / $3,985.00 / $4,782.00
| Professional | | $3,533.00 | $3,985.00 | $4,782.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.81 / $2,691.45 / $4,564.45
| Professional | | $2,527.81 | $2,691.45 | $4,564.45 |
- 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
- $2,638.04 / $5,115.06 / $7,351.06
| Professional | | $2,638.04 | $5,115.06 | $7,351.06 |