- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.40 / $1,750.40 / $1,750.40
| Professional | | $1,750.40 | $1,750.40 | $1,750.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.00 / $3,901.00 / $5,851.00
| Professional | | $3,251.00 | $3,901.00 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.42 / $2,919.82 / $3,748.64
| Professional | | $2,152.42 | $2,919.82 | $3,748.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.71 / $5,341.98 / $6,338.66
| Professional | | $2,416.71 | $5,341.98 | $6,338.66 |