- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.86 / $1,500.86 / $1,500.86
| Professional | | $1,500.86 | $1,500.86 | $1,500.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,432.00 / $3,870.00 / $4,644.00
| Professional | | $3,432.00 | $3,870.00 | $4,644.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.30 / $2,274.92 / $3,634.09
| Professional | | $2,171.30 | $2,274.92 | $3,634.09 |
- 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
- $2,532.75 / $4,948.34 / $6,332.03
| Professional | | $2,532.75 | $4,948.34 | $6,332.03 |