- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.62 / $1,450.62 / $1,450.62
| Professional | | $1,450.62 | $1,450.62 | $1,450.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,299.00 / $3,720.00 / $4,464.00
| Professional | | $3,299.00 | $3,720.00 | $4,464.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.05 / $2,056.60 / $3,463.15
| Professional | | $2,023.05 | $2,056.60 | $3,463.15 |
- 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
- $2,258.85 / $4,517.70 / $5,840.98
| Professional | | $2,258.85 | $4,517.70 | $5,840.98 |