- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.63 / $2,235.63 / $2,235.63
| Professional | | $2,235.63 | $2,235.63 | $2,235.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,576.00 / $5,491.00 / $8,839.00
| Professional | | $4,576.00 | $5,491.00 | $8,839.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.88 / $3,701.00 / $5,407.80
| Professional | | $2,904.88 | $3,701.00 | $5,407.80 |
- 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
- $3,256.54 / $5,510.36 / $8,799.12
| Professional | | $3,256.54 | $5,510.36 | $8,799.12 |