- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.37 / $1,540.37 / $1,540.37
| Professional | | $1,540.37 | $1,540.37 | $1,540.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,153.00 / $3,784.00 / $6,090.00
| Professional | | $3,153.00 | $3,784.00 | $6,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.12 / $2,555.94 / $3,658.28
| Professional | | $1,941.12 | $2,555.94 | $3,658.28 |
- 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
- $2,179.64 / $4,794.14 / $5,972.99
| Professional | | $2,179.64 | $4,794.14 | $5,972.99 |