- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.65 / $1,652.65 / $1,652.65
| Professional | | $1,652.65 | $1,652.65 | $1,652.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.00 / $4,061.00 / $6,538.00
| Professional | | $3,384.00 | $4,061.00 | $6,538.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.85 / $2,743.46 / $3,952.29
| Professional | | $2,099.85 | $2,743.46 | $3,952.29 |
- 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
- $2,358.40 / $4,006.40 / $6,428.40
| Professional | | $2,358.40 | $4,006.40 | $6,428.40 |