- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.88 / $1,473.88 / $1,473.88
| Professional | | $1,473.88 | $1,473.88 | $1,473.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,389.00 / $3,821.00 / $4,585.00
| Professional | | $3,389.00 | $3,821.00 | $4,585.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.52 / $2,065.65 / $3,467.06
| Professional | | $2,053.52 | $2,065.65 | $3,467.06 |
- 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
- $1,720.95 / $4,587.00 / $5,862.12
| Professional | | $1,720.95 | $4,587.00 | $5,862.12 |