- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,778.28 / $4,265.80
| Professional | | $1,737.80 | $1,778.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,570.88 / $5,495.41
| Professional | | $4,073.80 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,570.40 / $4,265.80
| Professional | | $2,511.89 | $2,570.40 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $6,606.93
| Professional | | $2,570.40 | $3,467.37 | $6,606.93 |