- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.75 / $1,687.75 / $1,687.75
| Professional | | $1,687.75 | $1,687.75 | $1,687.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,460.00 / $4,152.00 / $6,683.00
| Professional | | $3,460.00 | $4,152.00 | $6,683.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.14 / $2,805.80 / $4,036.79
| Professional | | $2,151.14 | $2,805.80 | $4,036.79 |
- 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
- $2,418.90 / $4,104.34 / $6,580.18
| Professional | | $2,418.90 | $4,104.34 | $6,580.18 |