- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,680.66 / $2,680.66 / $2,680.66
| Professional | | $2,680.66 | $2,680.66 | $2,680.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,164.00 / $4,970.00 / $5,964.00
| Professional | | $4,164.00 | $4,970.00 | $5,964.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $3,253.59 / $5,513.06
| Professional | | $2,675.00 | $3,253.59 | $5,513.06 |
- 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
- $3,159.75 / $4,814.39 / $7,468.50
| Professional | | $3,159.75 | $4,814.39 | $7,468.50 |