- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.76 / $1,794.76 / $1,794.76
| Professional | | $1,794.76 | $1,794.76 | $1,794.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,497.00 / $4,196.00 / $5,245.00
| Professional | | $3,497.00 | $4,196.00 | $5,245.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,443.57 / $2,995.82 / $4,261.60
| Professional | | $2,443.57 | $2,995.82 | $4,261.60 |
- 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
- $2,827.00 / $4,521.83 / $7,017.12
| Professional | | $2,827.00 | $4,521.83 | $7,017.12 |