- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.50 / $1,370.68 / $1,953.78
| Professional | | $1,321.50 | $1,370.68 | $1,953.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,775.00 / $4,530.00 / $7,008.00
| Professional | | $3,775.00 | $4,530.00 | $7,008.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.62 / $2,393.89 / $3,497.55
| Professional | | $1,484.62 | $2,393.89 | $3,497.55 |
- 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
- $1,560.88 / $2,967.92 / $5,854.21
| Professional | | $1,560.88 | $2,967.92 | $5,854.21 |