- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.67 / $1,513.67 / $1,513.67
| Professional | | $1,513.67 | $1,513.67 | $1,513.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,470.00 / $3,913.00 / $4,696.00
| Professional | | $3,470.00 | $3,913.00 | $4,696.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.69 / $2,127.23 / $3,604.18
| Professional | | $2,103.69 | $2,127.23 | $3,604.18 |
- 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
- $2,349.60 / $4,699.20 / $6,105.00
| Professional | | $2,349.60 | $4,699.20 | $6,105.00 |