- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.22 / $1,527.22 / $1,527.22
| Professional | | $1,527.22 | $1,527.22 | $1,527.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,129.00 / $3,755.00 / $6,046.00
| Professional | | $3,129.00 | $3,755.00 | $6,046.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.30 / $2,535.61 / $3,620.12
| Professional | | $1,946.30 | $2,535.61 | $3,620.12 |
- 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
- $2,185.69 / $4,371.39 / $5,166.20
| Professional | | $2,185.69 | $4,371.39 | $5,166.20 |