- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.40 / $1,750.40 / $1,750.40
| Professional | | $1,750.40 | $1,750.40 | $1,750.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.00 / $3,901.00 / $5,851.00
| Professional | | $3,251.00 | $3,901.00 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.17 / $2,919.82 / $4,113.67
| Professional | | $2,145.17 | $2,919.82 | $4,113.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.90 / $3,828.42 / $6,320.16
| Professional | | $2,396.90 | $3,828.42 | $6,320.16 |