- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.15 / $1,488.15 / $1,488.15
| Professional | | $1,488.15 | $1,488.15 | $1,488.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,403.00 / $3,838.00 / $4,606.00
| Professional | | $3,403.00 | $3,838.00 | $4,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.60 / $2,302.44 / $3,785.74
| Professional | | $2,153.60 | $2,302.44 | $3,785.74 |
- 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
- $1,971.54 / $4,905.84 / $6,339.98
| Professional | | $1,971.54 | $4,905.84 | $6,339.98 |