- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.75 / $1,544.75 / $1,544.75
| Professional | | $1,544.75 | $1,544.75 | $1,544.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,504.00 / $3,952.00 / $4,742.00
| Professional | | $3,504.00 | $3,952.00 | $4,742.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,177.71 / $2,205.08 / $3,699.99
| Professional | | $2,177.71 | $2,205.08 | $3,699.99 |
- 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
- $1,857.85 / $4,852.09 / $6,263.38
| Professional | | $1,857.85 | $4,852.09 | $6,263.38 |