- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.62 / $1,666.62 / $1,666.62
| Professional | | $1,666.62 | $1,666.62 | $1,666.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,807.00 / $4,293.00 / $5,152.00
| Professional | | $3,807.00 | $4,293.00 | $5,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.71 / $2,514.69 / $4,098.00
| Professional | | $2,412.71 | $2,514.69 | $4,098.00 |
- 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
- $2,797.84 / $5,495.43 / $7,015.81
| Professional | | $2,797.84 | $5,495.43 | $7,015.81 |