- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.15 / $1,400.15 / $1,400.15
| Professional | | $1,400.15 | $1,400.15 | $1,400.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,208.00 / $3,618.00 / $4,342.00
| Professional | | $3,208.00 | $3,618.00 | $4,342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.73 / $1,960.61 / $3,330.72
| Professional | | $1,955.73 | $1,960.61 | $3,330.72 |
- 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
- $2,192.29 / $4,384.59 / $5,662.79
| Professional | | $2,192.29 | $4,384.59 | $5,662.79 |