- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.55 / $1,522.55 / $1,522.55
| Professional | | $1,522.55 | $1,522.55 | $1,522.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,480.00 / $3,924.00 / $4,709.00
| Professional | | $3,480.00 | $3,924.00 | $4,709.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.28 / $2,154.61 / $3,818.97
| Professional | | $1,997.28 | $2,154.61 | $3,818.97 |
- 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
- $1,806.69 / $4,471.49 / $6,194.74
| Professional | | $1,806.69 | $4,471.49 | $6,194.74 |