- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.28 / $1,563.28 / $1,563.28
| Professional | | $1,563.28 | $1,563.28 | $1,563.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,582.00 / $4,039.00 / $4,847.00
| Professional | | $3,582.00 | $4,039.00 | $4,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,188.54 / $2,199.96 / $3,724.61
| Professional | | $2,188.54 | $2,199.96 | $3,724.61 |
- 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
- $2,458.50 / $4,021.35 / $6,337.34
| Professional | | $2,458.50 | $4,021.35 | $6,337.34 |