- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.48 / $1,324.48 / $1,324.48
| Professional | | $1,324.48 | $1,324.48 | $1,324.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,414.00 / $4,097.00
| Professional | | $3,028.00 | $3,414.00 | $4,097.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.00 / $1,956.79 / $3,312.27
| Professional | | $1,889.00 | $1,956.79 | $3,312.27 |
- 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
- $2,112.00 / $4,319.60 / $5,459.54
| Professional | | $2,112.00 | $4,319.60 | $5,459.54 |