- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.52 / $1,378.52 / $1,378.52
| Professional | | $1,378.52 | $1,378.52 | $1,378.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,150.00 / $3,552.00 / $4,262.00
| Professional | | $3,150.00 | $3,552.00 | $4,262.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.22 / $2,093.46 / $3,314.97
| Professional | | $1,993.22 | $2,093.46 | $3,314.97 |
- 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
- $1,804.79 / $4,541.13 / $5,819.89
| Professional | | $1,804.79 | $4,541.13 | $5,819.89 |