- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.05 / $1,551.05 / $1,551.05
| Professional | | $1,551.05 | $1,551.05 | $1,551.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,527.00 / $3,977.00 / $4,772.00
| Professional | | $3,527.00 | $3,977.00 | $4,772.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,192.71 / $2,211.08 / $3,689.08
| Professional | | $2,192.71 | $2,211.08 | $3,689.08 |
- 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
- $1,876.80 / $4,935.71 / $6,346.57
| Professional | | $1,876.80 | $4,935.71 | $6,346.57 |