- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.84 / $1,254.84 / $1,254.84
| Professional | | $1,254.84 | $1,254.84 | $1,254.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,317.00 / $2,780.00 / $4,170.00
| Professional | | $2,317.00 | $2,780.00 | $4,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.67 / $2,076.87 / $2,881.06
| Professional | | $1,665.67 | $2,076.87 | $2,881.06 |
- 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
- $1,862.30 / $3,934.50 / $4,914.35
| Professional | | $1,862.30 | $3,934.50 | $4,914.35 |