- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.10 / $2,512.10 / $2,512.10
| Professional | | $2,512.10 | $2,512.10 | $2,512.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,884.00 / $4,636.00 / $5,563.00
| Professional | | $3,884.00 | $4,636.00 | $5,563.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.00 / $3,043.12 / $5,158.64
| Professional | | $2,345.00 | $3,043.12 | $5,158.64 |
- 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
- $2,184.69 / $4,509.33 / $6,645.58
| Professional | | $2,184.69 | $4,509.33 | $6,645.58 |