- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.36 / $1,601.36 / $1,601.36
| Professional | | $1,601.36 | $1,601.36 | $1,601.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,658.00 / $4,125.00 / $4,950.00
| Professional | | $3,658.00 | $4,125.00 | $4,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,489.31 / $4,206.20
| Professional | | $2,481.10 | $2,489.31 | $4,206.20 |
- 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
- $2,094.69 / $5,279.52 / $7,128.00
| Professional | | $2,094.69 | $5,279.52 | $7,128.00 |