- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.50 / $1,700.50 / $1,700.50
| Professional | | $1,700.50 | $1,700.50 | $1,700.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,887.00 / $4,383.00 / $5,260.00
| Professional | | $3,887.00 | $4,383.00 | $5,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.86 / $2,435.42 / $4,077.09
| Professional | | $2,417.86 | $2,435.42 | $4,077.09 |
- 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
- $2,717.00 / $4,417.25 / $6,896.98
| Professional | | $2,717.00 | $4,417.25 | $6,896.98 |