- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.60 / $1,370.60 / $1,370.60
| Professional | | $1,370.60 | $1,370.60 | $1,370.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,940.00 / $6,370.00 / $7,644.00
| Professional | | $3,940.00 | $6,370.00 | $7,644.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.70 / $1,656.04 / $2,392.06
| Professional | | $1,226.70 | $1,656.04 | $2,392.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.56 / $2,517.96 / $3,913.92
| Professional | | $1,259.56 | $2,517.96 | $3,913.92 |