- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.40 / $1,989.40 / $1,989.40
| Professional | | $1,989.40 | $1,989.40 | $1,989.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,074.00 / $4,889.00 / $7,870.00
| Professional | | $4,074.00 | $4,889.00 | $7,870.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,557.75 / $3,297.85 / $4,781.71
| Professional | | $2,557.75 | $3,297.85 | $4,781.71 |
- 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
- $2,868.80 / $4,860.47 / $7,777.46
| Professional | | $2,868.80 | $4,860.47 | $7,777.46 |