- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.22 / $1,566.22 / $1,566.22
| Professional | | $1,566.22 | $1,566.22 | $1,566.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,545.00 / $3,998.00 / $4,798.00
| Professional | | $3,545.00 | $3,998.00 | $4,798.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.44 / $2,242.29 / $3,783.20
| Professional | | $1,736.44 | $2,242.29 | $3,783.20 |
- 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
- $1,473.21 / $3,862.11 / $6,403.30
| Professional | | $1,473.21 | $3,862.11 | $6,403.30 |