- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.34 / $1,392.34 / $1,392.34
| Professional | | $1,392.34 | $1,392.34 | $1,392.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,179.00 / $3,585.00 / $4,302.00
| Professional | | $3,179.00 | $3,585.00 | $4,302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.87 / $2,158.25 / $3,367.54
| Professional | | $2,018.87 | $2,158.25 | $3,367.54 |
- 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
- $1,816.64 / $4,593.70 / $5,913.58
| Professional | | $1,816.64 | $4,593.70 | $5,913.58 |