- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.49 / $1,553.49 / $1,553.49
| Professional | | $1,553.49 | $1,553.49 | $1,553.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,530.00 / $3,980.00 / $4,776.00
| Professional | | $3,530.00 | $3,980.00 | $4,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.85 / $2,217.53 / $3,724.82
| Professional | | $2,171.85 | $2,217.53 | $3,724.82 |
- 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
- $2,421.11 / $3,896.01 / $5,986.22
| Professional | | $2,421.11 | $3,896.01 | $5,986.22 |