- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.53 / $1,680.53 / $1,680.53
| Professional | | $1,680.53 | $1,680.53 | $1,680.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,099.00 / $3,719.00 / $5,578.00
| Professional | | $3,099.00 | $3,719.00 | $5,578.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.21 / $2,778.03 / $4,103.85
| Professional | | $2,203.21 | $2,778.03 | $4,103.85 |
- 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
- $2,461.25 / $5,449.17 / $6,559.09
| Professional | | $2,461.25 | $5,449.17 | $6,559.09 |