- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.96 / $1,536.96 / $1,536.96
| Professional | | $1,536.96 | $1,536.96 | $1,536.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,519.00 / $3,968.00 / $4,762.00
| Professional | | $3,519.00 | $3,968.00 | $4,762.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.10 / $2,156.57 / $3,662.96
| Professional | | $2,154.10 | $2,156.57 | $3,662.96 |
- 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
- $2,408.44 / $5,005.42 / $6,231.74
| Professional | | $2,408.44 | $5,005.42 | $6,231.74 |