- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.86 / $1,449.86 / $1,449.86
| Professional | | $1,449.86 | $1,449.86 | $1,449.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.00 / $3,747.00 / $4,496.00
| Professional | | $3,323.00 | $3,747.00 | $4,496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.73 / $2,063.53 / $3,452.00
| Professional | | $2,044.73 | $2,063.53 | $3,452.00 |
- 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
- $2,311.10 / $4,622.20 / $5,870.03
| Professional | | $2,311.10 | $4,622.20 | $5,870.03 |