- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.00 / $2,350.00 / $2,621.25
| Professional | | $2,300.00 | $2,350.00 | $2,621.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.28 / $3,181.50 / $4,217.74
| Professional | | $2,704.28 | $3,181.50 | $4,217.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $3,300.41 / $4,930.84
| Professional | | $150.00 | $3,300.41 | $4,930.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.75 / $3,431.60 / $4,100.50
| Professional | | $2,010.75 | $3,431.60 | $4,100.50 |