- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.52 / $1,434.52 / $1,434.52
| Professional | | $1,434.52 | $1,434.52 | $1,434.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,260.00 / $3,677.00 / $4,412.00
| Professional | | $3,260.00 | $3,677.00 | $4,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.10 / $2,037.95 / $3,390.55
| Professional | | $1,981.10 | $2,037.95 | $3,390.55 |
- 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
- $2,209.89 / $4,665.31 / $5,763.11
| Professional | | $2,209.89 | $4,665.31 | $5,763.11 |