- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.77 / $1,572.77 / $1,572.77
| Professional | | $1,572.77 | $1,572.77 | $1,572.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,594.00 / $4,052.00 / $4,862.00
| Professional | | $3,594.00 | $4,052.00 | $4,862.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.92 / $2,383.76 / $3,873.44
| Professional | | $2,275.92 | $2,383.76 | $3,873.44 |
- 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
- $2,034.54 / $5,183.29 / $6,633.00
| Professional | | $2,034.54 | $5,183.29 | $6,633.00 |